How Does ACA Marketplace Enrollment in 2026 Vary Across Congressional Districts?

Name: ACA Marketplace Enrollment in Some Congressional Districts in Florida, Texas, and Georgia Exceeds 100,000 People
Creator: KFF

Authors: Matt McGough, Justin Lo, and Cynthia Cox

Published: Oct 8, 2026

Enrollment in the Affordable Care Act (ACA) Marketplaces fell in 2026 for the first time in seven years, following the expiration of the enhanced premium tax credits at the end of 2025. Nationally, effectuated enrollment declined from 21.8 million people in 2025 to 19.2 million in February 2026, a 12% drop, and is expected to further decline through the remainder of 2026. A KFF survey of 2025 Marketplace enrollees found that 1 in 10 reported they had become uninsured in early 2026. For remaining enrollees, health costs have risen substantially, with premium payments rising 58% on average, and deductibles up by 37% or about $1,000 per person.

Changes in enrollment, however, were not evenly distributed across the country. Marketplace enrollment changed substantially from one state to another, and even within states. In some congressional districts, a sizable portion of the population are enrolled in ACA Marketplace plans, such as several districts in Florida in which almost 30% of the population is enrolled.

This analysis estimates how Marketplace enrollment varies both within and across states using both publicly available data on federally facilitated Exchanges (FFEs) from the Centers for Medicare and Medicaid Services (CMS) and data provided by state-based Exchanges (SBEs). Enrollment estimates are rounded to the nearest thousand. Key takeaways include:

Marketplace enrollment varies widely by congressional district: from as low as 2,000 people to 249,000 people.
In 12 Democratic districts and 16 Republican districts, more than 100,000 people are enrolled in an ACA plan, based on the incumbent representative. All these districts are in Florida, Texas, or Georgia.
Marketplace enrollment fell more sharply in Republican-held congressional districts, which account for 55% of current enrollees but 67% of the enrollment decline between 2025 and 2026.
The top 10 Republican districts with the highest number of Marketplace enrollees are: FL-27 (249,000), FL-28 (238,000), FL-26 (223,000), FL-11 (139,000), FL-21 (128,000), FL-18 (127,000), TX-15 (124,000), FL-19 (121,000), FL-05 (109,000), and FL-12 (105,000).
The top 10 Democratic districts with the highest number of Marketplace enrollees are: FL-24 (229,000), FL-25 (192,000), FL-20 (183,000), FL-10 (182,000), FL-09 (172,000), FL-22 (155,000), FL-23 (145,000), TX-28 (132,000), FL-14 (116,000), and GA-13 (109,000).

ACA Marketplace Enrollment in Some Congressional Districts in Florida, Texas, and Georgia Exceeds 100,000 People (Choropleth map)

The number of people enrolled in an ACA Marketplace plan varies widely across the country, reflecting differences in demographics, eligibility, the availability of other sources of coverage, and state Marketplace policies. Enrollment is generally highest in the South, where several states have not expanded Medicaid, leaving some low-income people eligible for subsidized Marketplace coverage instead. Florida has 21 congressional districts with more than 100,000 Marketplace enrollees, including the 11 districts with the highest enrollment nationwide. Texas and Georgia also have districts with more than 100,000 enrollees.

Marketplace enrollment is estimated to account for a large share of the population in several Florida districts, including 31% in FL-27, 30% in FL-28, 29% in FL-24, and 28% in FL-26. Districts in Georgia, Texas, and Utah also have Marketplace enrollment representing at least 10% of the population. Most ACA Marketplace enrollees (55%) live in a Republican-held congressional district. This is roughly proportionate to Republicans' share of House seats. Two-thirds of the enrollment decline between 2025 and 2026 occurred in Republican-held districts (67%).

Marketplace enrollment is much lower in states with broader public coverage options. Twenty-four of the 25 congressional districts with the lowest estimated Marketplace enrollment are in New York, each with less than 10,000 enrollees. Minnesota, Oregon, Kentucky, and Hawaii also have low ACA Marketplace enrollment. In the majority of their congressional districts, less than 3% of the population are enrolled in an ACA plan. All five states have expanded Medicaid eligibility up to 138% of the federal poverty line (FPL), and New York, Minnesota, and Oregon additionally offer Basic Health Plans that cover low-income residents.

Figure 2

ACA Marketplace enrollment represents a substantial share of the population in many states, but the share varies widely. Overall, the share of state populations enrolled in ACA Marketplace plans tends to be highest across the South, where several states have not expanded Medicaid, while shares are generally lower in the Northeast and Midwest. Thirteen states have greater than 5% of their population enrolled in ACA Marketplace coverage; they were all won by President Trump in 2024.

Florida has the highest share, with 16% of its population enrolled in a Marketplace plan, followed by Georgia (11%), Texas (10%), and Utah (10%). In contrast, enrollment accounts for less than 2% of the population in New York (1%), Hawaii (2%), Minnesota (2%), and the District of Columbia (2%).

Methods

To estimate effectuated enrollment by congressional district, effectuated enrollment was first determined at the county level and then allotted to congressional district. For states operating state-based exchanges (SBE), 2026 county enrollment data provided by the exchanges directly are February or first quarter effectuated enrollment, measured as of at least March 15. When county effectuated enrollment was not available, it was estimated by multiplying county plan selection counts by the state-level effectuation rate. This method was used to estimate enrollments for all counties in 2025, and in 2026, counties in FFM states and SBE states where only plan selection data were available (California, Idaho, Maryland, and Pennsylvania). County plan selections were obtained from the CMS Open Enrollment Period (OEP) County-Level Public Use File (PUF) for FFE states or directly from the SBE; state-level effectuation rate was derived from the OEP State-Level PUF and CMS’s Monthly Effectuated Enrollment data. Allocation of county effectuated enrollment to congressional district was based on the 2020 decennial census distribution using the Census Bureau block equivalency file for the 120^th Congress for all states except Missouri, which retained the block equivalency of the 119^th Congress.

Population estimates from 2026 are not yet available so data for 2025 were used, which may slightly overestimate the share of population enrolled in Marketplace coverage in states with large recent population growth. (For reference, state population change from 2024 to 2025 ranged from -0.3% in Vermont to +1.5% in South Carolina.) To estimate the population of each congressional district, state population estimates from Vintage 2025 of the Census Bureau Population Estimates Program were allocated to congressional districts using the population distribution from the Census Bureau 2024 American Community Survey 1-year estimates. A different method was used for states that recently redistricted: Alabama, California, Florida, Louisiana, North Carolina, Ohio, Tennessee, Texas, and Utah. In these states, the Vintage 2025 county population estimates were allocated to congressional district using the distribution from the 2020 decennial census.

Congressional district maps of effectuated enrollment account for redistricting ahead of the 120^th Congress. 2024 House race vote margins were marked as NA for districts with boundary changes after the 2024 election ahead of the 120^th Congress. These were identified by comparing Census Bureau block equivalency files for the 119^th and 120^th Congress for all states other than Missouri.

Appendix

ACA Marketplace Enrollment, by Congressional District, 2026 (Table)

VOLUME 56

October 8, 2026

AI in Health Care Moves Toward More Autonomous Roles

Joel Luther , Hagere Yilma , and Irving Washington

Highlights

Federal health agencies are testing new applications of AI in health care that move beyond narrow clinical support tasks into more direct patient care typically handled by physicians. Questions about AI accuracy remain, however, and may be complicated by unpredictable outputs and changes in performance over time.

Recent research also suggests that how health claims are presented may affect how people respond to them, beyond the accuracy of the underlying information. People may place more trust in information from an AI chatbot that offers conversational responses, while presenting false claims as coming from an authoritative source may increase people’s willingness to share them.

AI & Emerging Technology

Federal Officials Pilot AI Health Tools with Greater Autonomy as Accuracy Questions Remain

New federal pilot programs are testing AI tools that can perform clinical functions traditionally handled by physicians, including interacting directly with patients, providing therapy, diagnosing conditions, and recommending or adjusting treatment with less direct physician involvement. This marks a shift beyond AI’s more established role in narrower tasks, like reviewing scans or test results. According to The New York Times, more than 200 companies have received Centers for Medicare and Medicaid Services (CMS) approval to test AI tools like these, and the Food and Drug Administration (FDA) has allowed four of them for use with Medicare patients outside its standard approval process. The projects include an AI chatbot that delivers cognitive behavioral therapy and a federally funded project developing AI that would adjust medication for heart failure patients, under legally required physician oversight.

Perspectives about how much independence these systems should have vary. The American Medical Association, for example, has said that AI should continue to support rather than replace physician care. On the other hand, an August 2026 JAMA perspective piece argued that AI could soon match or exceed physicians at several tasks. Officials working on more autonomous AI systems have said that these tools that can act without a clinician directing each decision could expand access to care for people who can’t easily see a specialist.

Older AI-enabled medical devices already approved by the FDA for narrower tasks like reading a scan or test result have raised accuracy concerns. An August 2025 research letter in JAMA Health Forum examined 950 AI devices the FDA had cleared as of late 2024, finding that 60 were recalled a combined 182 times, mostly for diagnostic or measurement errors. Nearly half of those recalls happened within the device’s first year on the market. The FDA has said that newer uses of AI, including systems like those being piloted under Medicare, may be harder to evaluate than existing devices because they can produce unpredictable outputs and change over time. The agency has not yet established rules for evaluating this newer category of AI and is accepting public comment through October 19, 2026.

KFF polling from September 2025 found low levels of trust in health care apps that relied on AI to provide medical information: just one-third (32%) of the public said they would trust a health care app, website, or patient portal that uses artificial intelligence (AI) to access their medical records and provide personalized health information.

What To Watch Out For

As federal agencies test and set new rules for evaluating this newer category of AI tools, what standards will determine whether AI is accurate and safe enough to make clinical decisions with less direct physician involvement?

Conversational AI Chatbots and Perceived Authority May Shape Trust in Health Claims

Recent research suggests that people may place more trust in health information when AI appears conversational or when a claim is presented as coming from an authoritative source, even when the underlying information is wrong or weakly supported.

A more conversational AI chatbot led people to trust its answers more, in part because they perceived it as less rigid and more capable of subjective judgment, according to one recent experiment. This effect extended to claims that researchers described as “ridiculously wrong,” including a claim that ginger is more effective than chemotherapy for treating cancer. Giving participants the option to verify the chatbot’s answers did not produce a statistically significant change to their trust. Only those who clicked to check the information showed reduced trust, and only half of those offered the choice did so.

The apparent authority of who delivers an AI-generated health claim may have a similar effect on whether people say they’d share it. Researchers in China showed 320 older adults one of four AI-generated videos presenting the false health claim that combining vitamin B with dandelion tea could prevent or treat the flu. The videos varied who delivered the claim and how well-argued it was, portraying either an ordinary social media user or a supposed researcher wearing a lab coat. When the argument was weak, people who saw the video from the authoritative source were more likely to say they would share it than those who saw the video from the ordinary user. The difference was not significant when the argument was stronger, nor did stronger arguments make the claim itself appear more credible.

Whether perceived authority has a similar effect in the United States, where trust in scientists has declined in recent years but trust in doctors and health care providers remains high, is unclear. A similar finding has been documented, though, in research about false claims on social media. A recent study, including both an observational analysis of data from 8.7 million tweets and an experiment with U.S.-based participants, found that mentions of scientific authority were associated with a greater willingness to share, including when the underlying content was false. Polling from Pew Research Center has found that medical training, transparency, and clarity were the top three most important characteristics cited by the public when it comes to what they want from health information sources.

Why This Matters

Efforts to address false claims on AI platforms and social media may need to focus not only on the claims themselves, but also on making it easier for people to recognize when seemingly credible information should be verified. KFF’s Tracking Polls on Health Information and Trust have found that many adults who use AI for health information do not later follow up with a doctor, and most who use social media for health information similarly say they do not regularly follow up with providers or other sources to verify the accuracy of health information they come across.

What We’re Watching

As People Express Uncertainty on Health Claims, Health Care Providers Remain Influential Sources of Information

Polling from KFF and other organizations has found that many people are uncertain about health claims rather than consistently accepting or rejecting them. Majorities of adults in KFF’s polling on Health Information and Trust fall into the “malleable middle,” saying that claims are either “probably true” or “probably false.” In KFF’s June 2026 Tracking Poll on Health Information and Trust, for example, at least half of the public expressed uncertainty about four common vaccine myths, including that the measles, mumps, and rubella (MMR) vaccine had been proven to cause autism in children (61%) or that more people have died from COVID-19 vaccines than have died from COVID-19 itself (52%).

The recent 2026 Edelman Trust Barometer Special Analysis, conducted with the Yale School of Public Health, adds to this research by examining the range of sources people draw on when forming those views, including what they value from health care providers. The survey of adults across 13 countries asked about six claims, including about vaccines, fluoride, raw milk, and acetaminophen use during pregnancy. Similar to findings from KFF’s polling, few people believed all of the claims were true or false, with more expressing a mix of beliefs or saying that they did not know.

The Edelman analysis also provides insight into how people form these views, with respondents citing their own research and experiences, friends and family, news and social media, and health care providers. The influence of health care providers ranked highly regardless of how many health myths people believed, but those who believed three or more were more likely to cite a wider range of sources as influencing their beliefs, including AI platforms and content creators without medical training. KFF’s June 2026 Tracking Poll also found that frequent use of social media and AI for health information was associated with a greater tendency to believe vaccine myths.

Why This Matters

Many people express uncertainty about common health claims rather than firm views in either direction, and health care providers may play an important role in helping them work through that uncertainty. Respondents in the Edelman survey said that they valued providers who listened to their concerns, took their perspectives into account, and communicated with humility and respect. Similarly, KFF’s June 2026 poll found that adults who had a trusted health care provider were less likely than those with no trusted provider to believe vaccine myths. Understanding how providers can engage with people who are uncertain may be important for addressing health myths.

EPA Study of Mifepristone in Drinking Water May Shape Abortion Pill Debate, Even Before Its Findings Are Known

Despite a lack of evidence of any harms, the Environmental Protection Agency (EPA) is launching a national drinking-water study to test for the presence of mifepristone and misoprostol, two medications that are part of the medication abortion regimen. These drugs are also used for miscarriage management, to induce labor, and in the treatment of certain autoimmune diseases. This review is the latest development in a yearslong effort by some groups opposed to abortion to use environmental claims about the drug to restrict access. Earlier this summer, a journal run by anti-abortion physicians published a report purporting to show mifepristone in drinking water, but it only measured for any progesterone-blocking compound, not mifepristone specifically. The new EPA study, by contrast, aims to specifically measure for mifepristone, alongside more than 1,400 other pharmaceuticals, pesticides, and synthetic chemicals.

The EPA’s method, known as non-targeted analysis, can only detect whether a substance is present in a water sample, not its concentration or whether it poses any health risk. Despite the absence of any evidence documenting any harms, there have been claims that suggest that the public could face fertility or reproductive effects from exposure in water supplies. The report published earlier this summer made similar claims about the potential health effects of mifepristone in water, as have some anti-abortion state attorneys general and members of Congress. The FDA’s own environmental assessment of mifepristone, though, estimated concentrations under one part per billion, too low to impact standard test organisms.

Why This Matters

Having a major federal agency like the EPA decide to test for the drugs in drinking water may lend credence to these unsupported environmental claims, regardless of the agency’s eventual findings. False environmental claims about the harms of mifepristone have already been used to support proposed legislation in seven states and can shape public opinion regardless of the lack of documentation of any harm. Unsubstantiated claims about mifepristone in drinking water may cause unnecessary apprehension for people who already have concerns about fertility or reproductive health, making the distinction between just the ability to detect the drug in water supplies and establishing a concrete health risk especially critical.

More From KFF

About The Health Information and Trust Initiative: the Health Information and Trust Initiative is a KFF program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem. Our goal is to be of service to everyone working on health misinformation, strengthen efforts to counter misinformation, and build trust.

View all KFF Monitors

The Monitor is a report from KFF’s Health Information and Trust initiative that focuses on recent developments in health information. It’s free and published twice a month.

Support for the Health Information and Trust initiative is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF and KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities. The data shared in the Monitor is sourced through media monitoring research conducted by KFF.

Women’s Experiences with and Attitudes Towards Family Support Policies

Findings from the 2026 KFF Women’s Health Survey

Authors: Karen Diep, Usha Ranji, Brittni Frederiksen, Ivette Gomez, and Alina Salganicoff

Published: Oct 8, 2026

Section:

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There has been increased attention on declining fertility rates in the U.S. and globally. Fertility rates have been falling for many years, but they have been in the spotlight of media coverage recently, in part because of the current Administration’s focus on pronatalist policies aimed at encouraging people to have more children. Considerable financial and structural barriers face people who want to start families, including expensive and limited childcare options, inconsistent and limited paid leave and workplace flexibility, low economic mobility, and high cost of living.

The 2026 KFF Women’s Health Survey is a nationally representative survey of 4,688 women and 1,148 men ages 18 to 64, fielded between March 11, 2026 to April 14, 2026. This analysis presents data among women 18 to 49 (n=3,538) and men 18-49 (840), and highlights women’s opinions regarding the possible impact of potential federal actions on their decision to have children in the future as well their experiences with paid parental leave and sick leave in the workplace.

One in four women ages 18 to 49 say they are considering having children in the next three years. Less than a quarter of reproductive age women (23%) are considering having or adopting a child in the near future, including 24% of those who do not currently have children (under 18 years old). Six in ten women (63%) say they are not planning on having children in the next three years.
While the majority of reproductive age women say that greater family support policies such as assistance with childcare costs and mandatory paid parental leave would not affect their plans to have children, some say they would be more likely to consider growing their families if these policies were in place. Four in ten women say they are more likely to consider having children if the government assisted with childcare costs (43%) or required employers to offer paid parental leave (43%). This rises to about seven in ten among women who are already considering having a child in the near future. Half of men say these two policies would make them more likely to consider having children.
Compared to government assistance with childcare costs and mandatory paid parental leave, somewhat fewer women say the expansion of the child tax credit and one-time cash bonuses for a new child in the family would make them more likely to have children in the near future. One-third of reproductive age women say that if the government increased the child tax credit (35%) or provided a one-time cash payment to parents after welcoming a new child (35%), they would be much or somewhat more likely to consider having a child.
There is wide variation in the types and amount of parental leave women take, including whether they take any at all. Among employed women who had or adopted a child in the past three years, half (52%) took some amount of paid leave. About one-third (35%) took only unpaid leave, while more than one in ten (13%) did not take any leave after the arrival of their child. Among those who took leave, four in ten (37%) took up to two months of time in total, one third (34%) took between 9 to 12 weeks of leave, and 28% took more than 12 weeks off.
Women are the primary caretakers for children when they are sick at nearly three times the rate of men, and many women lose pay when they take time off. Nearly three times as many working women (58%) than men (20%) say they are the ones who care for their child when they are sick and cannot go to school. Among these women who care for their child either alone or with a partner, half (53%) report losing pay when they miss work.

Family Building

The majority of reproductive age women say they are not planning on having children in the next three years, including those who are already parents of a young child. About one in four women age 18 to 49 (23%) are considering having or adopting a child in the next three years (Figure 1). Larger shares of younger women between the ages of 18 and 25 (22%) and between 26 and 35 (33%) say they are planning on having children compared to women in their later reproductive years (13%). By political affiliation, more Republican women (29%) than Democrats (20%) plan on having children in the next three years. Almost half (45%) of reproductive age women are already parents to a child under 18 years old (data not shown). Half as many parents with older children (14%) than parents of younger children (28%) are planning on having another child in the next three years.

Stacked bars showing the share of women ages 18-49 considering having or adopting a child in the next 3 years with variation across age groups, income levels, partisanship, race/ethcnity, and parental status.

Influence of Potential Family Supports

The costs of having children and raising a family have never been higher. The current administration and other conservative policymakers have been pushing for young Americans to start families and have more children to address concerns about the declining birth rate in the U.S. They have discussed some ideas that they say would help, such as “Trump Savings Accounts,” a “motherhood medal” for women with six or more children, and most recently, using childcare subsidy funds to pay stay-at-home parents. The Administration has also proposed policies aimed at expanding access to fertility care such as in vitro fertilization (IVF), including discounts on medications and clarifying insurance rules for employers that want to offer fertility benefits to their workers.

Many factors come into play when people are thinking about having a child, including cost of living and income, the cost of raising a child, or certainty about having children. Previous KFF research has found that affordable and high-quality childcare is particularly daunting and difficult to find. Some policymakers have been advocating for policies that are intended to support families by offering broader financial assistance.

The survey probed whether people would be more likely to have children if the government did each of the following:

expanded the child tax credit
offered a one-time cash bonus for a new child in the family
provided more financial assistance with childcare costs
required employers to offer paid parental leave

Overall, less than half of reproductive age women say that enhanced family support policies would make them more likely to consider having a child.

About one-third of reproductive age women say that they would be much more likely or somewhat more likely to consider having a child if the government increased the child tax credit (35%) or provided a one-time cash bonus to parents after welcoming a child (35%). Most women say that these two policies would not have much or any impact on whether they have a child (Figure 2).

The federal child tax credit lowers the amount of taxes that parents/guardians of dependent children under age 18 owe. In 2021, the American Rescue Plan Act (ARPA), a COVID relief law, included a temporary expansion of the child tax credit. Research has found that the policy lowered the rate of child poverty, but that its economic benefits were uneven across different populations.

In the past few years, some states and locales have experimented with different models of cash payments to new parents, and recently, the Trump Administration launched tax-preferred investment accounts available to families with children, with the federal government providing an initial $1,000 deposit for the youngest children.

Stacked bar chart showing how increasing the child tax credit, one-time cash payments to parents, help with childcare costs, and paid parental leave would impact women and men in their consideration in having a child. Across all four, more men than women say that these family support policies would make them much or somewhat more likely to consider having children.

About four in ten reproductive age women say that if the government provided more financial assistance with childcare costs (43%) or required employers to offer paid parental leave (43%), they would be more likely to consider having a child, but half say that these two policies would have little or no impact. Higher shares of women who are Asian or Hispanic say they would be more likely to consider having a child if these policies were in place (Appendix Tables 3, 4).

Nationally, the average cost of childcare exceeds $13,000 annually, and many parents say that affordable childcare is difficult to obtain. Government assistance with childcare expenses can come in various forms, such as vouchers to help pay costs, public preschools, and tax incentives. Furthermore, the United States is one of the few industrialized nations that does not require employers to provide paid time off for new parents, but some states have enacted paid leave policies that cover a portion of their workers’ salaries.

Consistently, slightly higher shares of men than women say if the government required more family supportive policies that would make them more likely to consider having a child. More than four in ten men ages 18 to 49 say if the government increased the child tax credit (45%) or provided a one-time cash bonus to parents (46%) that they would be much more or somewhat more likely to consider having a child (Figure 2). About an equal share of men, though, say that these policies would not make much difference or any at all. Half of men say they would be more likely if the government provided more assistance with childcare costs or mandated paid parental leave. About four in ten men say these policies would not have much or any impact (Figure 2).

Compared to increased child tax credits and one-time cash incentives, government assistance with childcare expenses and mandatory paid parental leave would make reproductive age women more likely to consider having children, but the rates are highest among those already considering having children. About seven in ten reproductive age women who say they are considering having a child in the next three years also say they would be more likely to consider having a child if the government offered assistance with the costs of childcare (68%) or required paid parental leave (72%) (Figure 3). Notably, more than half of reproductive age women who are unsure about having a child in the next three years also say that support with childcare costs (57%) and paid parental leave (54%) would make them more likely to have children. However, just over one-third (37%) of women who are not considering having a child in the near future say these policies would affect their childbearing plans, but most say they would not make much difference or any at all.

Paid Parental Leave

Among the family support policies the survey asked about, the largest share of women said that paid parental leave would make them more likely to consider having a child. Paid parental leave benefits have been found to be associated with positive health outcomes, including shorter recovery times for women after childbirth, stronger bonding attachments with newborns, and greater access to breastfeeding. Yet, the United States is one of the few industrialized nations that does not have a national paid leave standard for parents caring for a new child or workers that need leave work to care for themselves or family members due to an illness or health condition. The federal Family and Medical Leave Act (FMLA) requires eligible employers to provide certain workers unpaid family leave, but only a minority of workers in the private sector have a paid family leave benefit. This gap has garnered increasing attention among elected officials at the national and local levels, and more than a dozen states now have paid leave policies in place.

More than half of women who had a child in the past three years (57%) were employed at the time, and about half (52%) took some paid time off after the arrival of their child (Figure 4). While most employed women took some time off work after childbirth or adoption, more than one in ten (13%) did not take any time off. Half (52%) took time off and were paid for at least a portion of that time, while 35% took only unpaid time off.

Among women who took leave after having a child, about four in ten took up to two months or 8 weeks of leave (Figure 5). There is a wide range in the amount of time women take off work after having a child in the U.S. Thirteen percent (13%) of women who had a child in the past three years report taking up to one month of leave, 24% took between five and eight weeks off, a third (34%) took between nine and 12 weeks, while only one in four took more than 12 weeks (28%). Twelve weeks is much shorter than the required maternity leave in most other developed countries, which averages around four months or 17 weeks of paid leave. The amount of parental leave women take in the U.S. is governed by several factors, including whether their employer is required by state law to offer parental and sick leave and the amount of wages they cover. Other factors affecting the amount of leave include their income, childcare availability, and their own or their infant’s health status and needs.

Pie chart showing the number of weeks of leave employed women took during their last childbirth or adoption. The majority of women took 12 weeks or fewer of leave, which includes paid and unpaid leave.

Paid Sick and Medical Leave

Like with parental leave, there is no federal law requiring employers to pay workers when they need time off to care for themselves, children, or other family members who are sick. However, far more employers do provide this benefit than not, and about eight in ten workers have some level of sick leave benefit. For workers with children, paid sick leave can allow them to stay home when their child is sick and cannot attend school without losing pay. Several states as well as cities require employers in their jurisdiction to provide a paid sick leave benefit to their workers.

Among working parents, a higher share of mothers than fathers report they are the ones that care for children when they are too sick to attend school. In addition to taking leave after the arrival of a child, many parents need to take time off when their children are sick and cannot attend school. Among working women, over half (58%) say they are the ones who usually take care of children when they are sick and cannot go to school, nearly three times the share of working fathers (20%) (Figure 6). One fifth (21%) of working mothers and three in ten working fathers (32%) say they share this responsibility equally with a spouse, partner, or co-parent. Only about one in ten (9%) working mothers say their spouse, partner, or co-parent usually takes on this responsibility, whereas this is the most common response among fathers (34%). Just over one in ten mothers (12%) and fathers (14%) say they can call someone else for childcare or their child can stay home alone. These numbers have remained steady over time and are similar to findings in 2022.

Grouped column chart showing that women 18 to 49 are the primary caregiver for their child if they are too sick to go to school or childcare.

About half of working mothers report losing pay when they miss work to care for sick children who can’t go to school. When parents miss work to take care of their sick children, 53% of mothers and 38% of fathers say they are not paid for that time (Figure 7). This has a disproportionate impact on mothers, as they are more likely to care for children when they are sick.

Loss of pay is more common among women who are Black (62%) and Hispanic (65%), compared to those who are White (50%). Approximately three in four (76%) mothers with low incomes report losing pay when they miss work to care for sick children, compared to four in ten of those with higher incomes (41%).

Bar chart showing that share of women and men who lose pay when they take time off to care for a sick child. Significantly larger shares of women than men say they lose pay, as well as larger shares of Black women, Hispanic women, and women who have low incomes and are uninsured or insured by Medicaid.

How Reproductive Age Adults Rate the Impact of a One-time Cash Payment on the Likelihood of Having a Child, by Selected Characteristics (Table)

How Reproductive Age Adults Rate the Impact of Increased Child Tax Credits on the Likelihood of Having a Child, by Selected Characteristics (Table)

How Reproductive Age Adults Rate the Impact of Government Assistance With Childcare Costs on the Likelihood of Having a Child, by Selected Characteristics (Table)

How Reproductive Age Adults Rate the Impact of Paid Parental Leave on the Likelihood of Having a Child, by Selected Characteristics (Table)

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

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

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

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

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

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

Group	N (unweighted)	M.O.S.E.
National Women Ages 18-49	3,538	± 2 percentage points
White, non-Hispanic	1,547	± 3 percentage points
Black, non-Hispanic	624	± 5 percentage points
Hispanic	946	± 4 percentage points
Asian or Pacific Islander	307	± 7 percentage points
<200% FPL	1,308	± 3 percentage points
200%+ FPL	1,958	± 3 percentage points
Private	2,131	± 3 percentage points
Medicaid	790	± 4 percentage points
Uninsured	457	± 6 percentage points
Democrat/Democrat leaning	1,765	± 3 percentage points
Independent	497	± 5 percentage points
Republican/Republican leaning	900	± 4 percentage points

General Notes:

Percentages may not add to 100%, or to subtotals indicated, due to rounding.
The “No answer” category includes refusals and those who volunteered “don’t know” responses.
The “Not sure” or “Don’t know” categories are only shown in tables when it was an explicit response option (i.e., shown on web or read via telephone) for survey respondents.
A category with ‘(VOL.)’ signifies a response option was not shown or read via telephone for survey respondents.
Insufficient sample size for analysis is denoted with “n/a” (e.g, FER4a). The sample size itself is shown, but the percentages are not.
Some survey questions were asked of males and females based on sex assigned at birth, which is shown in the base text above each question. However, the topline tables show results based on current gender identity.
Income is based on 2023 ASPE income levels. Two hundred percent (200%) of the federal poverty level (FPL) in 2023 for an individual was $29,160.
The sample primarily includes English-speaking Asian adults and, therefore, may not be representative of the overall Asian adult population. Despite this limitation, it is important to report the views of Asian adults on the topics in this study. As always, Asian adults’ responses are incorporated into the general population figures throughout this report.

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Women’s Access to Fertility Care

Findings from the 2026 KFF Women’s Health Survey

Authors: Usha Ranji, Karen Diep, Brittni Frederiksen, Ivette Gomez, and Alina Salganicoff

Published: Oct 8, 2026

Section:

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The high costs of in vitro fertilization (IVF), limited insurance coverage for fertility services, and intersection with state level abortion laws and fetal personhood policies have brought the issue of access to fertility care into the policy spotlight. President Trump has stated that he wants to make fertility care more affordable and said he would institute an insurance coverage mandate as part of his campaign promises. There is currently no federal requirement for insurance coverage of fertility services, and the Trump administration has not issued a proposal for one. Recently, the Trump Administration advanced a policy that offers a discount on some IVF medications for people without coverage through the TrumpRx website and clarified regulations about insurance options for employers to encourage them provide fertility benefits to those covered in their employer-sponsored health insurance policies. However, the Administration’s actions to date are likely to provide limited assistance for people seeking IVF services who have gaps in coverage and who are struggling to afford the costs. While several states have enacted laws requiring some level of fertility coverage in state-regulated plans, these laws have limited reach and only affect a minority of people with private insurance coverage given that most people with employer coverage are in self-insured plans.

To understand the need for and barriers to fertility services, the 2026 KFF Women’s Health Survey included questions on fertility care. The nationally representative survey was conducted from March 11, 2026 to April 14, 2026, online and by telephone. This analysis presents survey findings among women ages 18 to 49 (n=3,538) on their reported need for and use of fertility services.

Fifteen percent (15%) of reproductive age women say they or their partner have ever needed fertility services to help them become pregnant or prevent a miscarriage. However, not all actually received services. One in ten (11%) women ages 18 to 49 say they or their partner received fertility assistance, but a quarter of these women (3% of all reproductive age women) say they were unable to get the fertility care they needed.
The fertility services that reproductive age women most commonly use are fertility advice, fertility testing, and medications to improve ovulation. Only a fraction of this population say they have used IVF. Among women who say they or their partner ever needed fertility care, almost half (46%) say they received advice and 39% say they received testing services. As far as treatments, one-third (34%) say they have received drugs for ovulation. Thirteen percent (13%) of reproductive age women who say they or their partner ever needed fertility care report they received IVF, and 16% report they received artificial insemination (IUI), which translates to 2% of all reproductive age women who report ever receiving either service.
Cost is a major barrier to the receipt of fertility services for those who need them. Use of all fertility services is more common among women with higher incomes; among women who say they did not receive needed fertility care, the leading reason is cost. For example, among reproductive age women who say they or their partner have needed fertility assistance, 17% with higher incomes say they received IVF compared to just 3% of women with low incomes. Larger shares of women with low incomes report cost as the main barrier compared to those with higher incomes.

Need for Fertility Care and Cost Barriers

Approximately one in seven women ages 18 to 49 say they or their partner needed fertility assistance services at some point. Nationally, 15% of reproductive age women report needing fertility services to become pregnant or prevent a miscarriage at some time in their lives (Figure 1). The share reporting need increases with age, as fertility declines. Just over one in ten (12%) women ages 18 to 35 say they needed fertility services at some point, compared to 19% of women ages 36 to 49.

The reported need for fertility care is similar across most other demographic groups, except slightly lower among Black women (11%) compared to their White counterparts (17%). Nationally, 12% of women with lower incomes say they have needed fertility services, compared to 17% of women with higher incomes. About one in ten women with Medicaid coverage (11%) or who are uninsured (11%) say they have needed fertility services, lower than women with private insurance (17%). While the survey does not find differences across party lines of women reporting needing fertility care at some point, slightly more women who identify as pro-life (17%) say they or their partner has needed fertility services than women who are pro-choice (14%). Higher shares of women who identify as Protestants (16%) or Catholic (16%) report ever needing fertility assistance compared to those who do not follow a particular religion (11%).

Bar chart showing the share of women ages 18–49 who say they or their partner has ever needed medical assistance to become pregnant or prevent a miscarriage, overall, by age, race.ethnicity, income, insurance, party ID, abortion views, and religion. Fifteen percent of women say they or partner has needed assistance. Compared to their counterparts, this share is lower among women who are Black, have incomes less than 200% of poverty, have Medicaid or are Uninsured. Shares are slightly higher among women who are pro-life, Catholic, or Protestant.

Among all reproductive age women, about one in ten (11%) say they or their partner have received fertility services at some point. Another 3% say they needed services but were not able to obtain them (Figure 2). While a relatively small share of women say they could not obtain fertility services, they may not be able to grow their families as desired because they could not afford the care they needed to get pregnant. Most reproductive age women (85%) say they have never needed fertility services (includes women who have not yet tried to become pregnant as well as women who do not want to have children).

Pie chart showing the share of women ages 18–49 reporting whether they or their partner received the medical care they needed to become pregnant or prevent a miscarriage. Eighty-five percent of women say they or partner never needed fertility care. Eleven percent received the care that they needed, and three percent did not receive the care they needed.

Most women who say they needed fertility services received them, but the leading reason why women say they didn’t get needed fertility services is cost. Not surprisingly, cost barriers are more common among women with lower incomes.

There are many obstacles to receiving fertility care, including costs, coverage, provider availability, and health status. However, cost is by far the single largest barrier. Among reproductive age women who reported needing fertility services at some point, 25% (3% of all reproductive age women) say they did not receive these services and cost was the primary barrier.

Among the 15% of women who said they ever needed fertility services, one in five (21%) with lower incomes (21%) cite cost as the main reason they could not obtain fertility services, compared to 13% of women with higher incomes (Figure 3). Overall, this represents 3% of all reproductive age women with low incomes and 2% of those with higher incomes who say they did not obtain fertility services because of cost.

Coverage for fertility services is limited in both private insurance and Medicaid. The 2024 KFF Employer Health Benefits Survey found that about a quarter (27%) of large firms that offer health benefits cover IVF services. Some states require state-regulated private insurers – which do not include self-insured employer plans -- to cover some level of fertility services. Medicaid, the health coverage program for people with lower incomes, rarely covers fertility services. In fact, federal law exempts state Medicaid programs from a requirement to cover fertility medications, which is different from most other outpatient prescription drugs that are typically covered by the program.

Majority of Women Who Needed Fertility Services Say They Received Them, But Cost Is Leading Reason Some Did Not Receive Care (Stacked column chart)

Types of Fertility Services

The leading fertility services that women report receiving are advice, testing, and drugs to improve ovulation.

Fertility assistance encompasses a broad array of services, including advice and counseling, medications, surgical procedures, diagnostic tests, imaging studies, cryopreservation, intrauterine insemination (IUI), in-vitro fertilization (IVF), and surrogacy. Depending on individual circumstances, people may use a variety of these services to become pregnant and/or to prevent miscarriages, particularly if they have a history of or are at higher risk for pregnancy loss. The costs of services vary widely, ranging from a few hundred dollars for diagnostic tests and medications to upwards of $25,000 for one cycle of IVF, and some patients may need multiple cycles before they get pregnant.

Among the 15% of reproductive age women who ever needed fertility services, almost half said they received advice (46%). Four in ten said they received testing for themselves or their partner (39%), and about one-third (34%) obtained medications (e.g. clomid, hormones, etc.) to improve ovulation (Figure 4). One in ten (10%) women said they had a corrective surgery or used medications to address an issue that make getting pregnant or carrying a pregnancy difficult such as fibroids or endometriosis.

Among reproductive age women who said they or their partner ever needed fertility services, 13% report they received IVF and 16% report they received artificial insemination, also known as IUI. This translates to 2% of all reproductive age women who report receiving either IVF or IUI.

IVF is a costly medical procedure where eggs are removed from the ovary and are fertilized with sperm in a lab setting to create an embryo, which is then placed in the uterus. Artificial insemination, also known as Intrauterine insemination (IUI) is another fertility procedure that involves injecting sperm into the uterus. It is less invasive and less expensive than IVF and is often selected for those reasons.

While a relatively small share of people ever use IVF or IUI, many seek these services after trying a range of other services to get pregnant, such as medications, acupuncture, and surgeries.

Side by side bar chart showing the fertility services that women ages 18–49 say they or their partner received. Among women who needed medical care to become pregnant or prevent a miscarriage, forty-six percent received fertility advice, thirty-four percent received drugs to improve ovulation, and thirteen percent received IVF. This translates to less than ten percent for all services among the entire population of women ages 18 to 49.

Smaller shares of women with lower incomes report receiving fertility services.

A smaller share of women with low incomes report that they obtained fertility services. This is the case for diagnostic services such as fertility advice and testing as well as treatments, including ovulation drugs. For IVF, the most intensive and expensive service, 17% of women with higher incomes who needed fertility assistance obtained IVF, compared to 3% of women with low incomes (Figure 5).

Grouped column chart showing among the 15% of women ages 18–49, the services they report receiving. Fifty-three percent of women with incomes at least two hundred percent of poverty report receiving fertility advice, compared to thirty-two percent of women with incomes below two hundred percent of poverty. Thirty-eight percent of women with incomes at least two hundred percent of poverty report receiving drugs for ovulation, compared to twenty-four percent of women with incomes below two hundred percent of poverty. Seventeen percent of women with incomes at least two hundred percent of poverty report receiving IVF, compared to three percent of women with incomes below two hundred percent of poverty.

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

Group	N (unweighted)	M.O.S.E.
National Women Ages 18-49	3,538	± 2 percentage points
White, non-Hispanic	1,547	± 3 percentage points
Black, non-Hispanic	624	± 5 percentage points
Hispanic	946	± 4 percentage points
Asian or Pacific Islander	307	± 7 percentage points
<200% FPL	1,308	± 3 percentage points
200%+ FPL	1,958	± 3 percentage points
Private	2,131	± 3 percentage points
Medicaid	790	± 4 percentage points
Uninsured	457	± 6 percentage points
Democrat/Democrat leaning	1,765	± 3 percentage points
Independent	497	± 5 percentage points
Republican/Republican leaning	900	± 4 percentage points

General Notes:

Percentages may not add to 100%, or to subtotals indicated, due to rounding.
The “No answer” category includes refusals and those who volunteered “don’t know” responses.
The “Not sure” or “Don’t know” categories are only shown in tables when it was an explicit response option (i.e., shown on web or read via telephone) for survey respondents.
A category with ‘(VOL.)’ signifies a response option was not shown or read via telephone for survey respondents.
Insufficient sample size for analysis is denoted with “n/a” (e.g, FER4a). The sample size itself is shown, but the percentages are not.
Some survey questions were asked of males and females based on sex assigned at birth, which is shown in the base text above each question. However, the topline tables show results based on current gender identity.
Income is based on 2023 ASPE income levels. Two hundred percent (200%) of the federal poverty level (FPL) in 2023 for an individual was $29,160.
The sample primarily includes English-speaking Asian adults and, therefore, may not be representative of the overall Asian adult population. Despite this limitation, it is important to report the views of Asian adults on the topics in this study. As always, Asian adults’ responses are incorporated into the general population figures throughout this report.

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U.S. Foreign Aid Freeze & Dissolution of USAID: Timeline of Events

Authors: Jennifer Kates, Anna Rouw, and Stephanie Oum

Published: Oct 7, 2026

Starting on his first day of his second term in office, President Trump and his administration have taken several executive actions that directly impact U.S. global health efforts. This timeline, which is a companion resource to components of KFF’s Overview of President Trump’s Executive Actions on Global Health, provides a detailed overview of actions, including counter-actions, related to the administration’s efforts to freeze all U.S. foreign aid, dissolve the U.S. Agency for International Development (USAID), which implements most U.S. global health programs, and reorganize the Department of State. It will be updated as needed to reflect additional developments.

Overview of President Trump’s Executive Actions on Global Health

Authors: Jennifer Kates, Josh Michaud, Kellie Moss, Lindsey Dawson, and Anna Rouw

Published: Oct 7, 2026

Note: Originally published on Jan. 28, 2025, this resource is updated as needed, most recently on October 7, 2026, to reflect additional developments.

Starting on the first day of his second term, President Trump began to issue numerous executive actions, several of which directly address or affect U.S. global health efforts.* This guide provides an overview of these actions, in the order in which they were issued. The “date issued” is date the action was first taken; subsequent actions are listed under “What Happens/Implications.” See an accompanying timeline of events specific to the foreign aid review and USAID dissolution.

President Trump’s Executive Actions on Global Health

Initial Rescissions Of Harmful Executive Orders And Actions, January 20, 2025
PURPOSE: Initial rescissions of Executive Orders and Actions issued by President Biden. Among these orders are several that addressed the COVID-19 pandemic and global health security, such as Executive Order 13987 (Organizing and Mobilizing the United States Government To Provide a Unified and Effective Response To Combat COVID-19 and To Provide United States Leadership on Global Health and Security), which among other things established the National Security Council Directorate on Global Health Security and Biodefense and a Senior Director position to oversee it.	What Happens Next/Implications: Given that most of the provisions in the COVID-19 and Global Health Security actions issued by President Biden are no longer current or relevant, the rescissions of these actions are likely to have minimal effect on government policies. One exception may be the elimination of the Directorate of Global Health Security and Biodefense and its Senior Director at the National Security Council, which were responsible for interagency coordination on global health security matters during the Biden Administration. The elimination of this office echoes a similar move made during the first Trump Administration to eliminate an NSC Directorate for Global Health Security, and raises questions about who and which offices at NSC (and across the government) will fill this coordination role in the new Administration. More rescissions of other Biden administration Executive Actions may be issued at a later date.
Withdrawing The United States From The World Health Organization, January 20, 2025
PURPOSE: To withdraw from the World Health Organization (WHO). “The United States noticed its withdrawal from the World Health Organization (WHO) in 2020 due to the organization’s mishandling of the COVID-19 pandemic that arose out of Wuhan, China, and other global health crises, its failure to adopt urgently needed reforms, and its inability to demonstrate independence from the inappropriate political influence of WHO member states. In addition, the WHO continues to demand unfairly onerous payments from the United States, far out of proportion with other countries’ assessed payments. China, with a population of 1.4 billion, has 300 percent of the population of the United States, yet contributes nearly 90 percent less to the WHO.” ACTIONS: The United States intends to withdraw from the WHO. • The Presidential Letter to the Secretary-General of the United Nations signed on January 20, 2021, that retracted the United States’ July 6, 2020, notification of withdrawal is revoked. • Executive Order 13987 (Organizing and Mobilizing the United States Government to Provide a Unified and Effective Response to Combat COVID–19 and To Provide United States Leadership on Global Health and Security), which, among other things, called for “engaging with and strengthening the World Health Organization” is revoked. • Assistant to the President for National Security Affairs shall establish directorates and coordinating mechanisms within the National Security Council apparatus as necessary and appropriate to safeguard public health and fortify biosecurity. • The Secretary of State and Director of the Office of Management and Budget shall take actions to pause future transfer of any U.S. funds, support, or resources to WHO; recall and reassign U.S. government personnel or contractors working in any capacity with WHO; and identify credible and transparent U.S. and international partners to assume necessary activities previously undertaken by WHO. • The Director of the White House Office of Pandemic Preparedness and Response Policy shall review, rescind, and replace the 2024 U.S. Global Health Security Strategy. • The Secretary of State shall immediately inform the Secretary-General of the United Nations, any other applicable depositary, and the leadership of the WHO of the withdrawal. • While the withdrawal is in progress, Secretary of State will cease negotiations on the WHO Pandemic Agreement and the amendments to the International Health Regulations, and states that “actions taken to effectuate such agreement and amendments will have no binding force on the United States.”	What Happens Next/Implications: President Trump initiated a process to withdraw from the WHO during his first term in office, a process that takes a year to finalize, and halted funding. This time period was not met when President Biden took office and he reversed this decision and restored funding. Now, after issuance of a formal letter of withdrawal United Nations and WHO, the process will be initiated once again. Such a letter has been issued, indicating that membership will end as of January 22, 2026.Per the Executive Order, U.S. government representatives may not work with WHO. While U.S. representatives attended the Executive Board meeting in February (the U.S. previously held a seat on the Executive Board), no representatives attended the World Health Assembly in May, where world leaders adopted the Pandemic Agreement. On May 30, the White House released details on the President’s Budget Request for FY 2026, requesting eliminated funding for WHO. Further, on June 3, the administration asked Congress to rescind funds previously appropriated for fiscal years 2024 and 2025, including contributions to WHO. However, for both the FY 2026 appropriations and FY2024-25 rescissions, Congress will determine the final funding levels. As the largest donor to WHO providing approximately 16%-18% of the organization’s revenue, the absence of U.S. funding will have an impact WHO’s operations, as will the loss of U.S. technical expertise. See: KFF Fact Sheet and Quick Take Update: The formal withdrawal of the U.S. government from the WHO became effective on January 22, 2026.
Reevaluating And Realigning United States Foreign Aid, January 20, 2025
PURPOSE: To pause funding and review all U.S. foreign assistance to assess alignment with American values. The U.S. “foreign aid industry and bureaucracy are not aligned with American interests and in many cases antithetical to American values. They serve to destabilize world peace by promoting ideas in foreign countries that are directly inverse to harmonious and stable relations internal to and among countries.” “It is the policy of United States that no further United States foreign assistance shall be disbursed in a manner that is not fully aligned with the foreign policy of the President of the United States.” Calls for: • 90-day pause in U.S. foreign development assistance (new obligations or disbursements) to assess programmatic efficiencies and consistency with U.S. foreign policy. • Review of U.S. foreign assistance programs by the responsible department and agency heads under guidelines provided by the Secretary of State, in consultation with the Director of OMB. • Responsible department and agency heads, in consultation with the Director of OMB, will make determinations within 90 days of this order on whether to continue, modify, or cease each foreign assistance program based upon the review recommendations, with the concurrence of the Secretary of State. • New obligations and disbursements may resume for a program prior to the end of the 90-day period if a review is conducted, and the Secretary of State or his designee, in consultation with the Director of OMB, decide to continue the program in the same or modified form. Additionally, any other new foreign assistance programs and obligations must be approved by the Secretary of State or his designee, in consultation with the Director of OMB. • The Secretary of State may waive the pause for specific programs.	What Happens Next/Implications: Almost all global health programs are funded through foreign aid appropriations and are therefore subject to this order. The order temporarily freezes any new U.S. government spending (obligations or disbursements) through these programs, which could interrupt implementation of programs for which funds have not yet been obligated. It also calls for a 90-day review of all foreign aid programs. The 90-day review of foreign assistance was initially supposed to go through April 19, 2025, however, has been granted a 30-day extension. No formal results of the review have been announced. Key developments are as follows: • On January 24, 2025, A Notice on Implementation of the Executive Order was issued by USAID which, among other things, calls for stop-work orders to be issued for all existing foreign assistance awards (not just new obligations and disbursements). It notes that waivers have been granted for: foreign military financing for Israel and Egypt and emergency food assistance (and related expenses) and, on a temporary basis, salaries and related administrative expenses, including travel, for U.S. direct hire employees, personal services contractors, and locally employed staff. The stop-work order on existing awards halted U.S. global health (and other foreign assistance) programs that were already underway, placing key programs at risk of not being able to provide critical services, and affecting access for individuals on the ground, unless a waiver was received. • On January 28, the Secretary of State issued a blanket waiver for life-saving humanitarian assistance programs, which also lays out a process for requesting additional waivers (more information is here). This guidance also states that the waiver does not apply to “activities that involve abortions, family planning, conferences, administrative costs [unless associated with waived activities], gender or DEI ideology programs, transgender surgeries, or other non-life saving assistance.” • On February 1, PEPFAR, the global HIV/AIDS program, was granted a limited waiver enabling it to resume or continue “urgent life-saving HIV treatment services”, defined as a set of care and treatment services and prevention of mother-to-child transmission services. • On February 4, some additional services for other global health programs – tuberculosis; malaria; acute risks of maternal and child mortality, including severe acute malnutrition; and other life-threatening diseases and health conditions – deemed to be “lifesaving” were also granted a limited waiver to allow them to resume or continue. • On February 6, a lawsuit was filed by Democracy Forward and Public Citizen Litigation Group, on behalf of the American Foreign Service Association and American Federation of Government Employees, challenging the foreign aid funding freeze, the plan to put most staff on leave, and the fact that staff had already been placed on leave; on February 7, they filed a temporary restraining order (TRO). That same day, a temporary restraining order was issued by the U.S. District Court in the District of Columbia preventing the government from placing additional staff on leave or evacuating staff back to the U.S., and requiring reinstatement of all staff already placed on leave, until February 14. The court did not grant a TRO on the funding freeze, on the grounds that the plaintiffs in this case did not demonstrate that the freeze caused them irreparable harm. On February 13, the court extended the TRO through February 21 (further actions are described below, as this case was combined with another for purposes of the court’s consideration). • On February 10, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of two U.S. organizations seeking emergency relief from the freeze on funding for foreign assistance (AVAC v. United States Department of State). • On February 11, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of several U.S. organizations challenging the executive order and subsequent actions freezing foreign aid and dissolving USAID, and asking the court to temporarily restrain and preliminarily and permanently enjoin Defendants from implementing these actions (Global Health Council v. Trump). • On February 13, the court, in a ruling pertaining to the February 10 and February 11 lawsuits brought by numerous U.S. organizations, issued a TRO preventing the Trump administration from “suspending, pausing, or otherwise preventing the obligation or disbursement of appropriated foreign-assistance funds in connection with any contracts, grants, cooperative agreements, loans, or other federal foreign assistance award that was in existence as of January 19, 2025; or issuing, implementing, enforcing”, or “otherwise giving effect to terminations, suspensions, or stop-work orders in connection with any contracts, grants, cooperative agreements, loans, or other federal foreign assistance award that was in existence as of January 19, 2025.” • On February 14, the parties filed a joint status report proposing an expedited preliminary injunction briefing schedule. • On February 18, the government filed a required status report stating that, despite the TRO, it had the authority to cancel contracts and suspend grant awards. • This was followed by a February 19 request by the February 10 plaintiffs (AVAC v. Department of State) for an emergency motion to enforce the TRO and to hold the defendants in civil contempt. • The defendants filed a required response on February 20, stating that they have not violated the TRO and should not be held in contempt, which was again opposed by the plaintiffs. Also on February 20, the February 11 plaintiffs (Global Health Council v. Trump) filed a response to the defendant’s status report with a motion to enforce the TRO. The court reaffirmed the TRO on February 20 (but did not hold the defendants in contempt), stating it was prepared to hold a hearing on the preliminary injunction motions in both cases by March 4, 2025 and that the TRO would be in place through March 10, 2025, or the date the Court resolves the preliminary injunction motions, whichever is sooner. • The plaintiffs filed an emergency order to enforce the TRO on February 24, due to continued lack of payment, and the court issued a motion to enforce on February 25. The government appealed, (asking for a stay pending appeal) but this was denied by the court. The government then appealed to the Supreme Court and was granted a stay until February 28 while the case was considered. • On March 5, the Supreme Court denied the government’s request to vacate the federal district court’s TRO, sending the order back to the district court to clarify the government’s obligations for ensuring compliance with the TRO. • On March 6, the federal district court judge ordered the government to release all payments that were due to plaintiffs as of February 13, by Monday, March 10 at 6pm, and on March 10, the federal district court judge preliminarily enjoined the government from taking certain actions related to the foreign aid freeze. • On March 10, Secretary Rubio announced that a six-week review had been completed and that 83% of programs at USAID (5,200 contracts) had been cancelled. That same day, the court preliminarily enjoined the government from enforcing actions taken to implement the foreign aid freeze (requiring it to reverse any terminations, suspensions, and stop-work orders and to pay for any work completed by February 13). The court stated that the government was “enjoined from unlawfully impounding congressionally appropriated foreign aid funds and shall make available for obligation the full amount of funds that Congress appropriated for foreign assistance programs in the Further Consolidated Appropriations Act of 2024.” • On April 1, the government filed an appeal with the U.S. Court of Appeals for the District of Columbia challenging the preliminary injunction issued on March 10. • On April 17, the administration extended the foreign aid review for another 30 days from the original deadline of April 20, 2025. •On May 2 and May 30, the White House released information on its budget request for FY 2026, proposing significant decreases, and in some cases eliminations, of funding for global health activities. However, Congress will determine the final funding levels. • On June 3, the administration asked Congress to rescind previously appropriated funds for fiscal years 2024 and 2025, including $8.3 billion in foreign assistance, of which at least $1.2 billion was designated for global health. However, Congress will need to approve any potential rescissions. • On August 13, the U.S. District Court of Appeals for the District of Columbia Circuit partially vacated the March 10 preliminary injunction in the cases GHC v. Trump and AVAC v. State Department which required the government to make congressionally appropriated foreign assistance funds available for obligation. The appeals court ruled that the plaintiffs did not have the authority to challenge the President’s impoundment of funds. Instead, the court ruled that challenges of impoundment should be brought forward by the Comptroller General. • On August 28, the U.S. District Court of Appeals for the District of Columbia Circuit amended its opinion, clarifying that while plaintiffs did not have the authority to challenge impoundment of foreign assistance funds through the Impoundment Control Act, they could seek relief through the Administrative Procedures Act. Following this amended opinion, plaintiffs in GHC v. Trump and AVAC v. State Department cases motioned for a preliminary injunction in the U.S. district court on September 1. On September 3, the U.S. district court granted the preliminary injunction, ordering defendants to obligate expiring foreign assistance funds before the end of the fiscal year on September 30. On September 4, defendants appealed this preliminary injunction and requested a stay on the preliminary injunction pending the resolution of the appeals case, from both the district court and appeals court. These requests were both denied on September 5. On September 8, defendants requested a stay of the preliminary injunction as it pertained to funds included in the President’s proposed rescissions package from the U.S Supreme Court. On September 9, the Chief Justice of the Supreme Court granted a partial administrative stay of the preliminary injunction, and on September 26, the court granted the partial stay, allowing the administration to rescind the $4 billion that was in rescission package. Further legal proceedings in the case are currently stayed as the parties await the outcome of a separate legal case. • On July 27, 2026, plaintiffs in the GHC v. Trump case filed a motion requesting a summary judgment which would compel defendants to, among other things, obligate remaining foreign assistance and global health funds set to expire on September 30, 2026. On September 30, the court ordered a suspension of the September 30^th expiration date for unobligated funds set to expire then, allowing these funds to remain available for obligation until the suspension is lifted.
America First Policy Directive To The Secretary Of State, January 20, 2025
PURPOSE: To put core American interests first in foreign policy. The foreign policy of the United States “shall champion core American interests and always put America and American citizens first.” “As soon as practicable, the Secretary of State shall issue guidance bringing the Department of State’s policies, programs, personnel, and operations in line with an America First foreign policy, which puts America and its interests first.”	What Happens Next/Implications: The State Department is responsible for the supervision and overall strategic direction of foreign assistance programs administered by the State Department and USAID, which includes the vast majority of global health assistance. It also directly oversees PEPFAR, the global HIV/AIDS program, and many aspects of global health diplomacy for the U.S. Priorities and approaches for these and other global health programs are likely to be shaped by how the White House and State Department leadership define “America First” foreign policy and American interests, and how that definition is implemented in practice. Update: On September 18, the State Department released the America First Global Health Strategy, its new vision for U.S. global health engagement. The strategy is built around three pillars — “making America safer, stronger, and more prosperous” — and prioritizes funding for direct service support, such as commodities and health workers, includes plans for country co-investment, and seeks to transition program management operations from U.S. leadership to country ownership. The State Department is entering into multi-year bilateral agreements with recipient countries and implementation of these new agreements will begin sometime in 2026.
Defending Women From Gender Ideology Extremism And Restoring Biological Truth To The Federal Government, January 20, 2025
PURPOSE: To define sex as an immutable binary biological classification and remove recognition of the concept of gender identity. • The order states that “It is the policy of the United States to recognize two sexes, male and female” and directs the Executive Branch to “enforce all sex-protective laws to promote this reality”. Elements of the order that may affect global health programs are as follows: • Defines sex as “an individual’s immutable biological classification as either male or female”. States that “sex” is not a synonym for and does not include the concept of “gender identity” and that gender identity “does not provide a meaningful basis for identification and cannot be recognized as a replacement for sex.” • Directs the Secretary of Health and Human Services to provide the U.S. Government, external partners, and the public clear guidance expanding on the sex-based definitions set forth in the order within 30 days. • Directs each agency and all Federal employees to “enforce laws governing sex-based rights, protections, opportunities, and accommodations to protect men and women as biologically distinct sexes, including when interpreting or applying statutes, regulations, or guidance and in all other official agency business, documents, and communications. • Directs each agency and all Federal employees, when administering or enforcing sex-based distinctions, to use the term “sex” and not “gender” in all applicable Federal policies and documents. • Directs agencies to remove all statements, policies, regulations, forms, communications, or other internal and external messages “that promote or otherwise inculcate gender ideology”, and shall cease issuing such statements, policies, regulations, forms, communications or other messages. Directs agencies to take all necessary steps, as permitted by law, to end the Federal funding of gender ideology. • Requires that Federal funds shall not be used to promote gender ideology and directs agencies to ensure grant funds do not promote gender ideology. • Rescinds multiple executive orders issued by President Biden, including: “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (13988) and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (14075).	What Happens Next/Implications: This order is broad, directed to all federal agencies and programs. Because PEPFAR, and some other U.S. global health programs, serve people who are members of the LGBTQ community, guidance and implementation could affect the ability of these programs to reach individuals and organizations and provide them with services. In addition, the order will likely result in the removal of existing protections based on sexual orientation and gender identity, which had been provided in agency guidance for global health and development programs. Implementation guidance has been issued and all federal agencies must comply. Update: On January 27, 2026, citing this order (among others) the Trump administration released details of the “Promoting Human Flourishing in Foreign Assistance (PHFFA)” policy which significantly expands the Mexico City Policy (see below) to also prohibit the promotion of “gender ideology” and to apply to significantly more funding and organizations.
Memorandum For The Secretary Of State, The Secretary Of Defense, The Secretary Of Health And Human Services, The Administrator Of The United States Agency For International Development, January 24, 2025
PURPOSE: To reinstate Mexico City Policy and direct review of programs per the Kemp-Kasten Amendment. • Revokes President Biden’s Presidential Memorandum of January 28, 2021 for the Secretary of State, the Secretary of Defense, the Secretary of Health and Human Services, and the Administrator of the United States Agency for International Development (Protecting Women’s Health at Home and Abroad). • Reinstates President Trump’s Presidential Memorandum of January 23, 2017 for the Secretary of State, the Secretary of Health and Human Services, and the Administrator of the United States Agency for International Development (The Mexico City Policy). • Directs the Secretary of State, in coordination with the Secretary of Health and Human Services, to the extent allowable by law, to implement a plan to extend the requirements of the reinstated Memorandum to global health assistance furnished by all departments or agencies. • Directs the Secretary of State to take all necessary actions, to the extent permitted by law, to ensure that U.S. taxpayer dollars do not fund organizations or programs that support or participate in the management of a program of coercive abortion or involuntary sterilization.	What Happens Next/Implications: The Mexico City Policy is a U.S. government policy that – when in effect – has required foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. funds) as a condition of receiving U.S. global family planning assistance and, when in place under the Trump administration, most other U.S. global health assistance. First announced in 1984 by the Reagan administration, the policy has been rescinded and reinstated by subsequent administrations along party lines since, and expanded over time, including a significant expansion during the first Trump administration; it was widely expected that the President Trump would reinstate it in his second term and expand it further. The memorandum calls for the implementation of a plan to extend the requirements to global health assistance furnished by all departments or agencies; until the plan is ready, the scope of the new memorandum is unknown. The memorandum also directs the Secretary of State to review programs under the Kemp-Kasten amendment, a provision of U.S. law that states that no U.S. funds may be made available to “any organization or program which, as determined by the [p]resident of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.” It has been used in the past to prevent funding from going to UNFPA. See: KFF Mexico City Policy explainer and related resources and Kemp-Kasten explainer. Update: On January 7, 2026, the Trump administration announced that it had formally withdrawn from membership and participation in UNFPA, also citing the Executive Order on “Withdrawing the United States from and Ending Funding to Certain United Nations Organizations and Reviewing United States Support to All International Organizations.” Update: Three interim final rules expanding and implementing the Mexico City Policy, now called the Promoting Human Flourishing in Foreign Assistance (PHFFA) Policy, were issued on January 27, 2026: – Protecting Life in Foreign Assistance – Combating Gender Ideology in Foreign Assistance – Combating Discriminatory Equity Ideology in Foreign Assistance Rules This latest expansion now includes most non-military foreign assistance and applies to U.S. NGOs, international organizations, and foreign governments, as well as foreign NGOs. In addition to abortion, it also now prohibits the promotion of “discriminatory equity ideology” and “gender ideology.”
Renewed Membership in the Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family, January 24, 2025
PURPOSE: To rejoin the Geneva Consensus Declaration. The United States informed signatories of the Geneva Consensus Declaration of its intent to rejoin immediately. Established in 2020, the declaration, led by the United States, has the following objectives: “to secure meaningful health and development gains for women; to protect life at all stages; to defend the family as the fundamental unit of society; and to work together across the UN system to realize these values.”	What Happens Next/Implications: The Geneva Consensus Declaration, initially crafted and signed by the U.S. – along with 31 other countries at the time – was meant to enshrine certain values and principles related to women’s health and family, including a rejection of the “international right to abortion.” The Biden administration withdrew from the Consensus in 2021.
Review of and Changes to USAID, January 27, 2025 Reorganization of the Department of State, April 22, 2025
PURPOSE: To review and potentially reorganize USAID “to maximize efficiency and align operations with the national interest,” which may include the suspension or elimination of programs, projects, or activities; closing or suspending missions or posts; closing, reorganizing, downsizing, or renaming establishments, organizations, bureaus, centers, or offices; reducing the size of the workforce at such entities; and contracting out or privatizing functions or activities performed by federal employees.	What Happens Next/Implications: Related to but separate from the Executive Order on reevaluating and realigning foreign aid and on the America first policy directive to the Secretary of State, the administration has made changes to and begun a review of USAID, the U.S. government’s international development agency which oversees and/or implements most U.S. global health programs (see, The U.S. Government and Global Health). Key developments are as follows: • On January 27, senior USAID career staff were placed on leave and hundreds of other staff were let go. • On February 2, the USAID website was taken down. • On February 3, the USAID building in DC was closed, which has prevented other staff from accessing it. • The President appointed Secretary of State Rubio as Acting USAID Administrator on February 3. Secretary Rubio has said that the agency has “conflicting, overlapping, and duplicative functions that it shares with the Department of State” and that its systems and processes are not “well synthesized, integrated, or coordinated, and often result in discord in the foreign policy and foreign relations of the United States.” President Trump and other administration officials have called for dissolving the agency altogether. Formal notification of the intent to review the agency was sent by Secretary Rubio to Congress on February 3. • On February 4, a notice was posted on the USAID website stating that on February 7, all USAID direct hire personnel would be placed on administrative leave globally, with the exception of “designated personnel responsible for mission critical functions, core leadership and specially designated programs.” The notice also said that staff posted outside the United States would need to return to the U.S. within 30 days. • On February 6, a lawsuit was filed by Democracy Forward and Public Citizen Litigation Group, on behalf of the American Foreign Service Association and American Federation of Government Employees, challenging the foreign aid funding freeze, the plan to put most staff on leave, and the fact that staff had already been placed on leave; on February 7, they filed for a temporary restraining order (TRO). That same day, a temporary restraining order was issued by the U.S. District Court in the District of Columbia preventing the government from placing additional staff on leave or evacuating staff back to the U.S., and requiring reinstatement of all staff already placed on leave, until February 14. The court did not grant a TRO on the funding freeze, on the grounds that the plaintiffs in this case did not demonstrate that the freeze caused them irreparable harm. On February 13, the court extended the TRO through February 21, at which time, the court determined that further preliminary injunctive relief was not warranted and the TRO was ended, allowing the government to dismiss USAID staff. • On February 11, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of several U.S. organizations challenging the executive order pausing foreign aid, and subsequent actions freezing foreign aid and dissolving USAID, and asking the court to temporarily restrain and preliminarily and permanently enjoin Defendants from implementing these actions. In a February 13 ruling, a federal court issued a TRO preventing the Trump administration from freezing foreign aid assistance but stated that the proposed injunctions related to USAID were overbroad (in a separate case, the district court ended the TRO on dismissing USAID staff – see above). • On February 13, a lawsuit was filed in the U.S. District Court for the District of Maryland by 26 former and current employees of USAID, suing Elon Musk and DOGE for taking actions to control and dissolve the agency. On February 18, the plaintiffs filed a motion for preliminary injunction. The defendants responded on February 24 and the plaintiffs replied on February 26. On March 18, the court granted a preliminary injunction, requiring the defendants to reverse many of the actions taken to dissolve USAID, and on March 21, the defendants filed an appeal on the preliminary injunction. On March 25, the U.S. 4th Circuit Court of Appeals granted the defendants’ motion for a temporary stay on the preliminary injunction, allowing DOGE to resume its efforts to dissolve USAID, until March 27. The following day on March 28, the court granted defendants’ motion for a stay, clearing the path for DOGE to continue its work dissolving USAID. • On February 18, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of the Personal Services Contractor Association (representing USAID personal service contractors) challenging the suspension of foreign assistance and the actions related to USAID, including “steps to dismantle USAID, cripple its operations, or transfer its functions to the State Department without Congressional authorization”. On February 19, the plaintiffs filed a motion for a temporary restraining order. On March 6, the court denied the TRO request. • On March 28, Secretary Rubio announced that the Department of State and USAID have notified Congress on their intent to “undertake a reorganization that would involve realigning certain USAID functions to the Department by July 1, 2025, and discontinuing the remaining USAID functions that do not align with Administration priorities.” Additionally, nearly all the remaining USAID staff received notice that they would be subject to a final reduction-in-force. • On April 22, Secretary Rubio announced the Department of State’s reorganization plan and new organization chart. The plan states that it would consolidate functions and remove non-statutory programs that are “misaligned with America’s core national interests.” • On April 28, a lawsuit was filed by a group of labor unions, non-profits, and local governments challenging the administration’s moves to drastically reshape several federal agencies without congressional approval (American Federation of Government Employees v. Trump). The district court issued a TRO on May 9 and preliminary injunction on May 22 ordering the administration to pause large-scale reductions in force, program eliminations, and other actions related to federal agency restructuring. An emergency motion by the government for a stay pending appeal of the district court’s preliminary injunction was denied on May 30. • On May 2 and May 30, the White House released information on its budget request for FY 2026, noting the reorganization of USAID into the Department of State. • On May 29, the Department of State notified Congress of its reorganization plans, including absorbing USAID’s continued functions. • On June 13, the district court in American Federation of Government Employees v. Trump ruled that the actions of the Department of State, including the reorganization announcement and notification to Congress, were in violation of the preliminary injunction. • On July 8, the U.S. Supreme Court granted the government’s request for a stay of the preliminary injunction pending resolution of the appeals case in American Federation of Government Employees v. Trump, allowing the government to move forward with large-scale reductions to federal agency operations and workforces, including at the State Department. • On April 20, 2026, a congressional notification was sent to Congress outlining plans for USAID to use remaining funds, including $2 billion in FY25 funding from the Global Health Programs (GHP) account, to close out the agency and terminated awards. While initially created through Executive Order in 1961 as part of the State Department, the Foreign Affairs Reform and Restructuring Act of 1998 established it as an independent agency within the executive branch. As such, the Executive branch does not have authority to dissolve it without Congress, and Congress also requires notification first as well as consultation on any proposed changes. Update: On July 1, 2025, USAID was dissolved (with most employees being separated from the agency; any remaining personnel were separated by September 2, 2025). Remaining functions/activities were transferred to the State Department.
Withdrawing the United States From and Ending Funding to Certain United Nations Organizations and Reviewing United States Support to All International Organizations, February 4, 2025
PURPOSE: To review United States participation in all international intergovernmental organizations, conventions, and treaties and to withdraw from and end funding to certain United Nations (U.N.) organizations. • The U.S. “helped found” the U.N. “after World War II to prevent future global conflicts and promote international peace and security. But some of [its] agencies and bodies have drifted from this mission and instead act contrary to the interests of the United States while attacking our allies and propagating anti-Semitism.” • States that the U.S. “will reevaluate our commitment to these institutions,” including three organizations that “deserve renewed scrutiny”: a) the U.N. Human Rights Council (UNHRC; the U.S. will not participate in and withhold its contribution to the budget of the body), b) the U.N. Educational, Scientific, and Cultural Organization (UNESCO; the U.S. will conduct a review of its membership in the body within 90 days), and c) the U.N. Relief and Works Agency for Palestine Refugees in the Near East (UNRWA; reiterates that the U.S. will not contribute to the body). • Requires that within 180 days: a) the Secretary of State, with the U.S. Ambassador to the U.N., conduct a review of all international intergovernmental organizations of which the U.S. is a member and provides any type of funding or other support, and all conventions and treaties to which the United States is a party, to determine which organizations, conventions, and treaties are contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed; and b) the Secretary of State to report the findings of the review to the President, through the National Security Advisor, and provide recommendations as to whether the U.S. should withdraw from any such organizations, conventions, or treaties.	What Happens Next/Implications: With a long history of multilateral global health engagement, the U.S. is often the largest or one of the largest donors to multilateral health efforts (i.e., multi-country, pooled support often directed through an international organization). It provided $2.4 billion in assessed or core contributions in FY 2024 – 19% of overall U.S. global health funding – as well as more funding in voluntary or non-core contributions. The U.S. is also a signatory or party to numerous global health-related international conventions, treaties, and agreements; these include those that played a role in the global COVID-19 response (such as the International Health Regulations). It often has participated in negotiations for new international instruments, although the Trump administration indicated in a Jan. 20, 2025, Executive Order, listed above, that the U.S. would no longer engage in the Pandemic Agreement (sometimes called the “Pandemic Treaty”) negotiations. This Executive Order will have immediate impacts via the ordered actions related to the three U.N. organizations specified, much as the impacts of the Jan. 20, 2025, Executive Order on the World Health Organization (WHO, which initiated U.S. withdrawal from membership and halted U.S. funding) are already being seen. Beyond these, additional impacts of this Executive Order will be determined by the findings and recommendations of the international organizations and conventions review, particularly if U.S. support for or membership in some international organizations is recommended to be reduced or eliminated and if it recommends the U.S. withdraw from any international agreements. The 180 day review of all international intergovernmental organizations goes through August 3, 2025. Update: On January 7, 2026, the Trump administration announced that it had formally withdrawn from 66 international organizations, including United Nations entities and non-UN entities.
Memorandum For The Heads Of Executive Departments And Agencies, February 6, 2025
PURPOSE: The memorandum seeks to “stop funding Nongovernmental Organizations that undermine the national interest and administration priorities”. The memorandum: • States: it is Administration policy “to stop funding NGOs [Nongovernmental Organizations] that undermine the national interest.” • Directs heads of executive departments and agencies to review all funding that agencies provide to NGOs and “to align future funding decisions with the interests of the United States and with the goals and priorities of my Administration, as expressed in executive action; as otherwise determined in the judgment of the heads of agencies; and on the basis of applicable authorizing statues, regulations, and terms.”	What Happens Next/Implications: This memo aligns with other Executive actions that target federal funding for global health and foreign assistance programs. Implementation of this memo could result in the Administration halting funding to global health NGOs they determine “do not align with administration priorities.” No criteria for how this determination will be made has been provided. The majority of U.S. global health assistance is channeled through NGOs. In FY22, for example, 62% of U.S. global health funding was provided to NGOs as prime partners (45% to U.S.-based NGOs and 17% to foreign-based NGOs) and others are likely sub-recipients of U.S. assistance.* As such, this Order could have a significant impact on NGOs if it is determined that they do not align with administration policies. *Source: KFF analysis of data from www.foreignassistance.gov.
Addressing Egregious Actions of The Republic of South Africa, February 7, 2025
PURPOSE: To stop U.S. support for South Africa due to its “commission of rights violations in its country or its ‘undermining United States foreign policy, which poses national security threats to our Nation, our allies, our African partners, and our interests.” “It is the policy of the United States that, as long as South Africa continues these unjust and immoral practices that harm our Nation: (a) the United States shall not provide aid or assistance to South Africa; and (b) the United States shall promote the resettlement of Afrikaner refugees escaping government-sponsored race-based discrimination, including racially discriminatory property confiscation.” ACTIONS: • All executive departments and agencies, including USAID, shall, to the maximum extent allowed by law, halt foreign aid or assistance delivered or provided to South Africa, and shall promptly exercise all available authorities and discretion to halt such aid or assistance. • The head of each agency may permit the provision of any such foreign aid or assistance that, in the discretion of the relevant agency head, is necessary or appropriate. • The Secretary of State and the Secretary of Homeland Security shall take appropriate steps, consistent with law, to prioritize humanitarian relief, including admission and resettlement through the United States Refugee Admissions Program, for Afrikaners in South Africa. A plan shall be submitted to the President through the Assistant to the President and Homeland Security Advisor.	What Happens Next/Implications: South Africa receives a significant amount of global health assistance, particularly for HIV/AIDS, from the United States government. The executive order allows the heads of U.S. agencies to permit the provision of foreign aid or assistance under this order at their discretion. On February 10, the U.S. Embassy and Consulates in South Africa announced that PEPFAR would not be impacted by this Executive Order and could continue under the limited waiver already granted to the foreign aid funding freeze. No other exceptions have yet been announced. The Government of South Africa has issued a statement in response to the Executive Order that, among other things, expresses concern “by what seems to be a campaign of misinformation and propaganda aimed at misrepresenting our great nation.”

Notes and Sources:

*There are several other Executive Actions issued by the President that instruct all government agencies on a variety of topics and as such broadly affect global health program operations but are not specific to global health. These include, for example, Executive Actions withdrawing from the Paris Agreement under the United Nations Framework Convention on Climate Change and ending DEI programs. These are not included in this resource.

Sources: White House, https://www.whitehouse.gov/presidential-actions/; State Department, www.state.gov.

First Look at New Hospital Price Transparency Provisions: Some Factors Complicate Price Comparisons

Authors: Gary Claxton, Lynne Cotter, Shameek Rakshit, and Matthew Rae

Published: Oct 7, 2026

This analysis takes a first look at how hospitals are reporting prices under updated federal hospital price transparency requirements that took effect in January 2026. The hospital price transparency (HPT) rule requires most non-federal hospitals to publish their standard charges for each item and service they provide.

The analysis describes several key issues with how hospitals are reporting rates and other required information, which limits the usefulness of the new data for researcher comparing hospital prices. Notably, the negotiated payment arrangements between hospitals and payers are complicated and can take many forms, making it difficult to accurately compare prices across hospitals.

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

Which States Will Be Affected by Key Medicaid Provisions in the 2025 Reconciliation Law?

Authors: Alice Burns, Jennifer Tolbert, Robin Rudowitz, and Anthony Montano

Published: Oct 7, 2026

Amidst challenging fiscal conditions and upcoming national and state elections, states are working to implement major federal changes to Medicaid. The 2025 reconciliation law made major changes to federal revenues and spending. Shortly after enactment, the Congressional Budget Office (CBO) estimated the new law would reduce federal spending on Medicaid by $911 billion over the 2025–2034 period and that the Medicaid changes would increase the number of people without health insurance by 7.5 million in the year 2034. Recognizing the risks such changes posed for rural areas, policy makers added a $50 billion rural health transformation program (referred to here as the “rural health fund”) to the reconciliation law. All 50 states have received first-year allotments from the rural health fund and are implementing new initiatives to support rural health care, although these funds will not offset reductions in federal Medicaid support.

Even before the new restrictions take effect, the landscape is evolving, making it difficult to isolate the effects of the changes in the law. Medicaid enrollment is declining, and states are facing tight fiscal conditions due to slowing revenue growth and increased spending pressures. The forthcoming policy changes from the 2025 reconciliation law are expected to increase coverage loss, decrease provider reimbursement rates, and place new strain on state budgets. Some more recent estimates of the law’s provisions—such as those included in proposed or final regulations—are not comparable to the older CBO estimates because they cover different time periods, use different baseline projections of spending and health coverage, and have different assumptions about how states, providers, and people will respond to the changing Medicaid policies.

Although current estimates of the effect of the law on Medicaid are not available—and are unlikely to be available in the future, this policy watch illuminates how the impacts will vary across states by showing which key eligibility and financing provisions are expected to affect each state and Washington DC (hereafter referred to as a state). Some provisions in the law affect all states, while some provisions only apply to certain states. The effects of many provisions vary by state and states that have adopted the Affordable Care Act (ACA) Medicaid expansion face the most restrictions (Figure 1). In many cases, the full effects of the law are still unknown and will depend on how federal rules are finalized and how states implement the changes. Many of the changes are administratively challenging for states to implement. Those challenges could be amplified in the 36 states with gubernatorial elections in 2026 if the election results in a change of administration. With only 17 incumbent governors currently on the ballot, at least 19 states are expecting some change in leadership.

All States Face Major Changes to Medicaid Stemming from the 2025 Reconciliation Law (Bar Chart)

Which States Will Be Affected by Key Medicaid Eligibility Changes?

The reconciliation law included Medicaid eligibility policies that will lead to fewer people being covered by Medicaid and disproportionately apply to Medicaid expansion states. The most substantial changes include new work requirements, more frequent eligibility redeterminations for expansion adults, and restrictions on Medicaid eligibility for immigrants (Figure 2). The law also reduces the availability of retroactive coverage to pay incurred medical expenses to two months for traditional enrollees and one month for expansion enrollees and imposes new cost-sharing requirements on expansion adults with income 100–138% of the federal poverty level (FPL, Appendix Table 1). While states will face increased administrative costs to implement these changes, lower Medicaid enrollment could reduce state and federal Medicaid costs. However, the drop in Medicaid enrollment over time may shift costs from states to providers as more people become uninsured but still have health care needs. States required to implement key Medicaid eligibility changes include:

Forty-four states are required to implement new work requirements on certain adults. These states, including 41 expansion states and 3 non-expansion states, will be required to condition Medicaid eligibility for enrollees with coverage through the ACA Medicaid expansion or under certain waivers on meeting work requirements or qualifying for an exclusion.
Forty-one Medicaid expansion states will need to increase the frequency of eligibility redeterminations for expansion adults from annually to every six months. This new 6-month renewal period only applies to expansion adults; states must maintain the 12-month renewal period for other populations eligible on the basis of modified adjusted gross income (MAGI), including most children, pregnant individuals, and parents who are not enrolled in expansion coverage.
All states must restrict eligibility for certain lawfully present immigrants. As of October 1, 2026, all states are required to limit Medicaid eligibility to only certain lawfully present immigrants, eliminating eligibility for many other groups of lawfully present immigrants, including refugees and asylees without a green card, among others.

The 2025 Reconciliation Law Requires All States to Make Eligibility Changes (Choropleth map)

Which States Will Be Affected by Key Medicaid Financing Changes?

The reconciliation law makes major changes to Medicaid financing that will affect how states can raise the state share of Medicaid payments and how they can pay providers. Changes to Medicaid financing include new limits on provider taxes that constrain all states in their ability to raise future revenues from provider taxes and further limit the amount of revenues ACA expansion states are permitted to collect. Those new limits are likely to exacerbate states’ current fiscal challenges and may force states to make additional reductions in Medicaid spending. Changes to provider payment rates primarily stem from new limits on state directed payments (SDPs), which cap future payment rates at or near the rates paid by Medicare in all states. Unless states can offset this funding loss, providers are likely to face a significant drop in Medicaid payments at the same time they are experiencing revenue losses resulting from fewer people having health insurance. Although the rural health fund does not offset the loss of federal Medicaid revenues, it may help the 50 states that are receiving funding to adapt their systems to the loss of revenues. However, the extent to which any benefits from these initiatives persist after the time-limited funds are exhausted remains unknown.

Beyond limiting states’ future use of provider taxes, the law may reduce revenues from existing taxes in nearly all states that have adopted the ACA Medicaid expansion. New limits on provider taxes effectively prohibit all states from establishing new provider taxes or increasing the rates of existing taxes, thus limiting one tool states may have used to respond to the 2025 reconciliation law’s reduction in federal funding. For ACA expansion states, the 2025 reconciliation law decreases the percent of net patient revenues (currently 6.0%) that can be collected for all provider taxes except those on nursing facilities and intermediate care facilities. Starting October 1, 2027, the limit will decrease by 0.5 percentage points each year, until it reaches 3.5%. As of 2025, 31 states reported having current taxes that are above 3.5% of net patient revenues and subject to the new limits (Figure 3). A proposed rule to implement the reconciliation law requirements would expand the new limits to include health insurer taxes, likely affecting additional states.

The 2025 Reconciliation Law Limits All States in Their Ability to Collect Provider Taxes (Choropleth map)

At least 41 states have SDPs, which govern the payments managed care organizations make to health care providers and could be affected by new limits in the 2025 reconciliation law. Most SDPs are for hospital services, and most set payment rates at or near rates paid by private health insurance plans. Starting January 1, 2028, payment rates for hospital services will decrease in at least 37 states with directed payments that exceed the new limits. KFF estimates that the federal government spends $93 billion on SDPs each year, $78 billion of which pays for hospital services. Of the $78 billion on hospital services, an estimated $60 billion exceeds the new payment limits and could be reduced as the reconciliation law limits take effect. Some states will be far more affected than others, with over half of the spending above new limits coming from only eight states (California, Illinois, Kentucky, Texas, North Carolina, Louisiana, Arizona, and Michigan).

Provider Payment Rates Could Be Affected by New Limits on SDPs in At Least 41 States (Stacked Bars)

All 50 states (not including Washington DC) are receiving money from the rural health fund, but the amount they are receiving per rural resident ranges from $66 (Texas) to $6,305 (Rhode Island). The rural health fund will provide grant funding to states for a period of five years, with $10 billion awarded across the states each year. First-year awards range from $147 million in New Jersey to $281 million in Texas (Appendix Table 2). Ten states’ awards are less than $100 per rural resident, but eight states’ awards are greater than $500 per rural resident. The range in funding reflects a financing formula that awards 50% of the total amount equally among all states, 25% based on “state need” (which reflects the characteristics of the states’ rural geographies, populations, and providers), and 25% based on states’ proposed initiatives (which reflects states’ plans and their use of initiatives consistent with the priorities of the current administration).

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Appendix

The 2025 Reconciliation Law Requires All States to Make Eligibility Changes (Table)

The 2025 Reconciliation Law Affects Medicaid Financing in All States (Table)

Midterm Election Update: Vaccines

Published: Oct 6, 2026

Federal vaccine policy has shifted toward fewer recommended routine childhood vaccinations, more emphasis on individual decision-making, and greater skepticism about the safety and efficacy of some vaccines. In response, some states are relying less on federal recommendations in setting vaccination requirements. The changes coincide with declining childhood vaccination rates, rising exemptions from school vaccine requirements, and a major measles resurgence. The public’s trust in federal health officials remains low.

Overview

Since January 2025, the Trump administration has made major changes in federal vaccine policy, including which vaccines the federal government recommends, who makes those recommendations, and the kinds of messages that it is providing to the public.

The changes represent a shift from an expert-driven federal vaccine framework with broad support for routine childhood immunizations toward narrower federal recommendations, fewer recommended childhood vaccinations, greater state variation and greater reliance on individual decision-making. They are unfolding against a backdrop in which childhood vaccination rates were already declining and as vaccine-preventable diseases such as measles are resurging in several states.

Key Developments

Health and Human Services Secretary Robert F. Kennedy Jr., a longtime critic of federal vaccine policy who has questioned the safety and effectiveness of vaccines, has spearheaded the overhaul. Kennedy also is a leading figure in the Make America Healthy Again (MAHA) movement, which has elevated issues such as vaccine safety, the role of corporate interests in federal health agencies, and the presence of chemicals in the food supply.

In June 2025, Kennedy fired and replaced all the members of the Advisory Committee on Immunization Practices (ACIP), the expert panel charged with providing evidence-based recommendations to the Centers for Disease Control and Prevention (CDC).

During 2025, among other policy changes, the CDC revoked its recommendation that healthy children and pregnant women receive routine COVID-19 vaccines and later, in line with guidance from the reconstituted ACIP, revised its immunization schedule to recommend “shared clinical decision-making” for COVID-19 vaccines. In December, ACIP members voted to end the 34-year-old recommendation that all newborns receive the hepatitis B vaccine within 24 hours of birth.

That same month, federal health officials made vaccination reporting measures voluntary rather than mandatory in Medicaid and the Children’s Health Insurance Program, which could make it harder to monitor and understand vaccination trends for children.

The most significant changes came in January 2026, when HHS adopted a substantially revised childhood vaccination schedule. This reduced the number of diseases targeted from 17 to 11 and the number of routine vaccines from 13 to 7, making the U.S. an outlier among peer nations. As a result, six vaccines are no longer recommended for routine use by all children in the U.S.: rotavirus, COVID-19, influenza, hepatitis A, hepatitis B, and meningococcal vaccines. Some of these vaccines are now recommended for a narrower group of children, and all six have been moved from the routine category of vaccination to “shared clinical decision making.” (A federal judge has temporarily blocked the revised HHS recommendations.)

In August, The White House released an executive order reiterating the changes to the childhood vaccination schedule. It also called on the HHS Secretary to offer some childhood vaccines such as measles, mumps, and rubella (MMR) as “single vaccines rather than combination products”, meaning they would be delivered in three separate shots rather than in a single vaccination covering all three.

More generally, President Trump and Secretary Kennedy have repeatedly raised safety concerns about vaccines, including advancing the idea that vaccines cause autism and linking childhood vaccinations with a rise in chronic diseases in children — assertions for which there is no evidence.

At the state level, at least nine states have enacted changes since 2025 that make non-medical exemptions to mandatory school vaccinations more permissive, including by reducing documentation or procedural requirements. Research indicates that easier-to-obtain non-medical exemptions are associated with higher exemption rates and declining childhood vaccination coverage.

Recent Issues and Looking Ahead

In response to the federal changes, a growing number of states has begun to separate their vaccination requirements from federal recommendations. As of August 2026, 30 states and DC had announced they would no longer follow CDC/ACIP recommendations for one or more childhood vaccines, with 27 states delinking from CDC/ACIP recommendations for all childhood vaccines. States are relying instead on prior recommendations, state recommendations, and/or the guidance of external entities such as the American Academy of Pediatrics (AAP) in shaping their state vaccination requirements for children.

The federal changes also have raised concerns about insurance coverage of vaccines. Many private insurers, Medicaid programs, and the federally funded Vaccines for Children program are required to cover ACIP-recommended vaccines without cost-sharing. Changes in recommendations can affect which vaccines insurers must cover at no cost. In practice, the effects vary because states can establish additional requirements, particularly for state-regulated insurance plans and school entry. As a result, vaccine recommendations and potentially the coverage available to families can differ by state. For now, insurers have said they will continue to cover the same vaccinations, and the federal court ruling means the HHS changes to the childhood vaccination schedule remain blocked.

All of this is occurring in a landscape in which childhood vaccination rates were already falling. Data show that 92.4% of kindergarteners had been vaccinated against measles, mumps, rubella (MMR) and polio and 92.0% against DTaP (diphtheria, tetanus, and acellular pertussis) for the 2025-2026 school year. That was down from 95% across all three vaccines for the 2019-2020 (pre-pandemic) school year and below coverage levels of the past decade. At the same time, the share of kindergarteners with exemptions from one or more school vaccination requirements rose to 4.2%, up from 2.5% in 2019-2020.

A vaccination rate of at least 95% is needed to prevent community transmission of measles. Thirty-nine states had MMR coverage below the 95% level, and 18 states were below 90%.

Although measles has been officially “eliminated” from the U.S. since 2000, measles cases have surged over the past two years. In 2026, the U.S. has reported nearly 3,887 confirmed cases of measles as of October 1, more than in any year since 1991, already exceeding the total for all of 2025 and putting the U.S.’s elimination status at risk. Measles cases have been reported in most states, with South Carolina, Utah, Pennsylvania, Texas, and Virginia seeing the largest outbreaks so far in 2026.

The Public’s Views

KFF polling finds that the public’s trust in the CDC remains at its lowest point following the Trump administration’s revisions to the childhood vaccination schedule. Fewer than half (47%) now say that they trust the agency at least “a fair amount” to provide reliable vaccine information, down more than 10 percentage points since the beginning of the second Trump administration, and continuing a downward trend first measured during the COVID-19 pandemic. Views differ along partisan lines, and the recent decline reflects falling confidence in the CDC among Democrats.

About four in ten voters approve of the Trump administration’s handling of vaccine policy (38%) while six in ten disapprove (61%). Democrats hold the advantage over Republicans in whom voters trust to handle vaccine policy (41% vs. 25%), though one quarter trust neither party. While some of the administration’s vaccine policy changes may have been intended to appeal to MAHA voters, among voters who support MAHA, four in ten say lowering health care costs should be the government’s top health care priority, while only one in ten choose reevaluating vaccine safety.

KFF Experts

Jen Kates, a Senior Vice President and Director of the Global and Public Health Policy Program

Josh Michaud, an Associate Director for Global and Public Health Policy

Liz Hamel, a Senior Vice President and Director of Public Opinion and Survey Research

Journalists with questions about this topic should reach out to KFFMedia@kff.org.

Midterm Election Update: The Affordable Care Act Marketplaces

Published: Oct 6, 2026

More people than ever got coverage through the Affordable Care Act (ACA) Marketplaces in 2025, but the expiration of enhanced premium tax credits has driven up what people pay and contributed to declining enrollment in 2026. Law and regulatory changes also tightened ACA eligibility and enrollment requirements, including for some lawfully present immigrants. Public opinion of the ACA remains generally favorable, although views remain divided along partisan lines.

Overview

The Affordable Care Act (ACA) Marketplaces, sometimes called Obamacare markets, allow individuals and families who don’t get coverage from other sources to buy their own insurance, often with the help of federal tax credits based on income to make comprehensive coverage more affordable.

Effectuated enrollment – that is, the number of people who paid their premiums – climbed to a record 21.8 million in 2025 in large part due to more generous temporary enhanced premium tax credits. These enhanced tax credits reduced premium payments for lower and middle-income Marketplace enrollees and also made some upper-middle class and higher-income enrollees newly eligible for financial assistance. The enhanced tax credits were first passed as part of a relief package during the COVID-19 pandemic and later extended temporarily by the Inflation Reduction Act.

The expiration of those temporary tax credits at the end of 2025 sharply increased what people have to pay out of pocket toward premiums. The total cost of marketplace insurance also is on the rise, with insurers seeking a median premium increase of about 15% for 2027. While the remaining tax credits will protect most enrollees from the full impact of next year’s premium hikes, those with higher incomes who are no longer eligible for financial assistance would have to pay the full costs.

There are also concerns about how shrinking enrollment and rising prices will affect the marketplace’s stability going forward. Some insurers cite a deteriorating risk pool as a factor in rate increases as healthier enrollees drop coverage rather than paying more, and some insurers plan to leave some ACA markets.

Key Developments

As part of the 2025 reconciliation law, sometimes called “the One Big Beautiful Bill,” Congress created new pre-enrollment verification requirements, which could effectively end autorenewals starting in 2028; required enrollees who underestimated their incomes at the start of the year to fully repay any excess tax credits; and prohibited many lawfully present immigrants from receiving ACA tax credits.

The Trump administration also finalized stricter enrollment and eligibility procedures, including additional verification of income, household information, immigration status, and other eligibility details. Many of these requirements, as well as other changes included in a 2026 regulation, are on hold due to pending litigation but could lead to further enrollment decline if implemented.

The reconciliation law enacted in July 2025 did not address the expiring enhanced premium tax credits. Late last year, Republicans in Congress blocked efforts by Democrats to extend the tax credits before they expired, arguing that they were so generous that they allowed insurers to charge more and encouraged improper or fraudulent enrollment.

The Trump administration also is working to make it easier for consumers to enroll in alternatives to ACA Marketplace coverage, such as short-term limited duration health plans. Unlike Marketplace insurance, short-term plans can reject consumers based on their medical history. Enrollees are also not eligible for any of the ACA’s premium tax credits, meaning they have to pay the full cost themselves regardless of their income.

In September, the Trump administration announced it would send $500 check to nearly 1 million ACA Marketplace enrollees in 30 states – a small share of current enrollees. Enrollees who won’t get rebates include those in mostly blue states that run their own Marketplace and those who receive premium tax credits, even though what they’re paying has gone up. The Administration also announced it would cancel coverage for more than 760,000 people it says were improperly enrolled and did not respond to a request for more information within 30 days. That process likely resulted in some legitimately enrolled consumers losing their coverage.

Recent Issues and Looking Ahead

After the temporary tax credits expired, what people would have to pay in premiums after accounting for tax credits increased by 114% or more than $1,000 annually to stay in the same plan in 2026. Facing higher premium payments, some dropped coverage, while some others switched to lower-premium plans with higher deductibles. On net, premium payments increased 58% on average (as opposed to 114%), but deductibles increased by 37% or about $1,000 more per person due to many people buying down to lower levels of coverage. Eight in ten of those who chose to remain in the marketplace say their health care costs went up, and more than half said they were cutting back on other expenses to afford the increases.

Effectuated enrollment in Marketplace plans fell for the first time in seven years, from 21.8 million last year to 19.2 million in 2026. Enrollment dropped in every state except New Mexico, which offered state subsidies to replace the expired tax credits. Enrollment is expected to drop further this year, potentially as low as 17.5 million, as consumers wrestle with higher premium payments.

Looking ahead, the Congressional Budget Office projected that the reconciliation law’s ACA provisions alone would increase the number of uninsured by 2.1 million by 2034. Combined with the law’s Medicaid changes and the expiration of the enhanced tax credits, the estimated increase in the uninsured by 2034 topped 14 million people.

The Public’s Views

Most of the public views the ACA favorably as it has since 2017, when congressional Republicans failed to repeal the law during the first Trump administration. As of March, 61% of the public hold favorable views, while 38% hold unfavorable views. Views diverge by political party, with nine in ten Democrats and nearly two thirds of independents (64%) viewing the law favorably, while two thirds of Republicans (67%) hold unfavorable views.

Support for extending the ACA’s enhanced tax credits was also strong throughout 2025. Earlier this year, two thirds of the public (67%), including strong majorities of Democrats and independents, said that Congress did the wrong thing by failing to extend the tax credits. Most Republicans (63%) said Congress did the right thing.

KFF Experts

Larry Levitt, Executive Vice President for Health Policy

Mollyann Brodie, Executive Vice President and Chief Operating Officer, and Executive Director of Public Opinion and Survey Research

Cynthia Cox, Senior Vice President and Director of the Program on the ACA

Liz Hamel, Senior Vice President and Director of Public Opinion and Survey Research

Kaye Pestaina, Vice President and Director of the Program on Patient and Consumer Protection

Journalists with questions about this topic should reach out to KFFMedia@kff.org.

How Does ACA Marketplace Enrollment in 2026 Vary Across Congressional Districts?

Methods

Appendix

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