Introduction

Title 42 of the Public Health Services Act is a public health authority that authorizes the Director of the Centers for Disease Control and Prevention (CDC) to suspend entry of individuals into the U.S. to protect public health. This rarely utilized authority was implemented by the Trump administration in March 2020 in response to the COVID-19 pandemic to allow for quick expulsion of migrants, including asylum seekers, seeking entry into the U.S. at the land borders. After a series of delays due to court challenges, the restrictions were lifted when the Biden Administration declared an end to the COVID-19 public health emergency (PHE) on May 11, 2023. The Biden administration subsequently took increasingly restrictive executive action to restrict border entry.

Land border entries into the U.S. decreased as a result of Title 42 since individuals who had border encounters under this authority were immediately expelled due to the public health threat outlined by the Trump administration. However, research suggests that Title 42 restrictions did not result in a “better managed border” and increased cases of unauthorized re-entry, and public health experts stated that it put the health and well-being of migrants at risk. Recent reports suggest President-elect Trump may reinvoke Title 42 restrictions during his second term to close the border between the U.S. and Mexico, along with a number of other actions to restrict immigration.

This brief provides an explanation of Title 42 and its application in border regions, the impact of Title 42 on border expulsions and the health and well-being of migrants during COVID-19, and a discussion of the potential implications of reinvoking Title 42 restrictions for immigration and the health of migrants.

What are policies for migrants seeking entry at the U.S. border?

Under U.S. immigration law, individuals have a legal right to claim asylum when presenting at U.S. ports of entry. An asylee is an individual already present in the U.S. or seeking admission at a port of entry who is seeking protection based on “persecution or a well-founded fear of persecution on account of their race, religion, nationality, membership in a particular social group, or political opinion.” In fiscal year (FY) 2023, the U.S. granted asylum to over 54,000 individuals from close to a dozen different countries. However, as of October 2024, over 90% of asylum cases filed in FY 2023 were still pending with only 2% being granted approval due to immigration backlogs.

Migrants encountered at the border are processed and screened for asylum under Title 8 of the U.S. Code addressing “Aliens and Nationality.” Under Title 8, those determined to have a credible fear of persecution or other threats in their home country are either held in custody or released into the U.S. while their case is pending in immigration court. Those who the U.S. Citizenship and Immigration Services (USCIS) determine not to have a credible fear are permitted to appeal this decision to an immigration judge. If an individual chooses not to appeal or the immigration judge did not find fear, then the individual is removed.

In June 2024, the Biden administration took executive action to suspend and limit the entry of migrants at the southern border, including asylum seekers, to “address the historic levels of migration and more efficiently process migrants arriving at the southern border.” Under this rule, the suspension of entry will go into effect immediately after there have been 2,500 or more average daily border encounters (not including unaccompanied children) over seven consecutive days and can be lifted once there have been fewer than 1,500 average daily border encounters over seven consecutive days. As of April 2024, there were about 4,000 average daily border encounters, leaving the restrictions in place. U.S. Customs and Border Patrol (CBP) data show that border encounters following the executive order were at a three-year low with there being a 29% reduction in encounters between May and June 2024.

How did Title 42 change policy for migrants seeking entry at the border during the COVID-19 pandemic?

In March 2020, the Trump administration implemented Title 42 under the Public Health Service Act, which allowed for the immediate expulsion of migrants without screening for asylum. This order applied to all migrants arriving to the U.S. from Canada or Mexico regardless of their country of origin who would otherwise be held in a congregate setting at a port of entry or border patrol station. It did not apply to lawful permanent residents and their families, members of the armed forces or their families, or people who hold valid travel documents such as tourists or those in a visa waiver program. Officials also had authority to make exceptions for individuals on a case-by-case basis. Under this order, the CDC Director was authorized to “suspend the introduction of persons into the United States” and CBP officials were directed to process migrants promptly (within 15 minutes in an outdoor setting) without screening for asylum and expel them back to Mexico or Canada or their country of origin. The CDC stated the purpose of the order was to protect CBP personnel, U.S. citizens, lawful permanent residents, and other individuals from an increase in COVID-19 spread at land ports of entry, Border Patrol stations, and in the interior of the country. The order pointed to the introduction of individuals into congregate settings at the border and the increased strain this would put on the U.S. health care system during a public health emergency as primary reasons for implementing the restrictions on entry.

Title 42 continued to be enforced under the Biden administration until the end of the COVID-19 PHE declaration in May 2023. However, unaccompanied minors were exempted from the order based on a district court ruling in November 2020 and by a CDC order issued under the Biden administration in February 2021. The CDC order continued to apply the original Title 42 order to single adults and families. After facing legal challenges, Title 42 restrictions were lifted in May 2023 following the end of the COVID-19 PHE declaration.

How did implementation of Title 42 impact immigration and the health of migrants?

Between FY 2021¹  and 2023, there were over 6.5 million encounters at the Southwest land border of which about four in ten (41%) were under Title 42 authority. Enforcement encounters refer to “apprehensions or inadmissibles processed under CBP’s immigration authority;” these include individuals apprehended under Title 8 as well as individuals expelled under Title 42. While Title 42 applies to both the Northern and Southwestern Borders, nearly all Title 42 encounters occurred at the Southwestern Border. Between FY 2021 and FY 2023, Title 42 encounters at the Southwest Border accounted for about four in ten (41%) of all Southwest Border encounters. The share of encounters that were under Title 42 varied by demographic group with Title 42 accounting for a majority (56%) of single adult encounters and one in six (17%) family encounters, while Title 8 accounted for virtually all (99%) encounters with unaccompanied minors reflecting their exemption from expulsion under Title 42 (Figure 1).

As of May 2023, there were over 2.5 million single adult expulsions, nearly 320,000 expulsions of individuals in a family unit, and nearly 16,000 expulsions of unaccompanied minors under Title 42. The number of family expulsions under Title 42 grew between FY 2020 and FY 2021, while expulsions of unaccompanied minors decreased, reflecting their exemption beginning in February 2021. These encounter counts reflect repeat encounters with individuals, as each attempt by the same individual to cross the border is counted as a new encounter.

Data indicate that Title 42 did not lead to a reduction in border encounters, but border entries into the U.S. went down due to the nature of the authority. While Title 42 was intended to reduce COVID-19 exposure risk at the border, it led to an increasing number of encounters at the border largely due to repeat encounters. This is in large part because, unlike Title 8, migrants apprehended under Title 42 were immediately expelled and those with repeat encounters did not face any penalties. Data from 2020 through 2023 suggest that while there were close to 3 million Southwest border expulsions under Title 42 authority, many of those expulsions were of the same individuals making repeated attempts to cross the border. In the last 6 months of 2021, a quarter of the encounters under Title 42 were of the same individuals on multiple occasions, with recidivism rates under the authority being at their highest levels in over a decade. In addition, there has not been a significant increase in border encounters since Title 42 was lifted with border encounters in FY 2024 (2.1 million) being lower than border encounters in FY 2022 (2.4 million) and FY 2023 (2.5 million). However, entries into the U.S. through land borders decreased as a result of Title 42 since individuals who had border encounters under this authority were immediately expelled due to the public health threat outlined by the Trump administration.

Research suggests Title 42 expulsions negatively impacted the health and well-being of migrant families while having little to no impact on preventing the spread of COVID-19 in the U.S. Physicians, epidemiologists, and public health experts repeatedly stated that Title 42 was counterproductive to preserving health and protecting individuals from COVID-19. Physicians suggested that being in close proximity with other individuals while being temporarily detained or transported back to Mexico, lack of medical screenings, and lack of provision of necessary medication could have adverse impacts on physical and mental health. Typically, the CDC recommends that asylees be provided an initial medical screening within 30-60 days of arriving in the U.S., but since Title 42 called for immediate expulsion, such screenings were not provided. Interviews conducted with over two dozen asylum seekers who were expelled under Title 42 authority found that a vast majority reported symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD), and many reported that their children’s mental health was also impacted. Sending individuals back to potentially dangerous situations they were fleeing also poses risks. Title 42 may also have contributed to increases in family separations at the border. Media reports suggested that some families were separating from their children so that the children could seek entry as unaccompanied minors, who were exempt from Title 42 expulsions. These separations may have led to children facing dangerous situations traveling to the border and expose them to trauma and toxic stress. The impact of Title 42 on migrant families may also have been exacerbated by the “Remain in Mexico” or Migrant Protection Protocols program implemented under the first Trump administration, which required thousands of migrants (including children) to wait for their U.S. immigration court hearings in Mexican border towns that can be dangerous and unsafe. Close to 80% of migrants receiving medical treatment from Doctors without Borders/Medecins Sans Frontieres at border locations in Nuevo Laredo, Mexico, reported being victims of violence, with many experiencing depression, severe anxiety, and post-traumatic stress.

What are the potential implications of reinvoking Title 42?

The incoming Trump administration has indicated plans to reinvoke Title 42. President-elect Trump has proposed an array of policies focused on restricting immigration. Recent reports suggest that the incoming Trump administration is planning to reinvoke Title 42 to restrict immigration under the rubric of public health protection. Experiences during COVID-19 suggest Title 42 was not effective at reducing border encounters or preventing COVID-19 and had negative health impacts for migrants. Reinvocation of such a policy also raises questions about its use as a border enforcement tool and could potentially fuel xenophobic sentiment towards immigrants.

1. U.S. Customs and Border Protection, “Nationwide Enforcement Encounters: Title 8 Enforcement Actions and Title 42 Expulsions Fiscal Year 2021”. Accessed January 2025. ↩︎

With the incoming Trump administration and Republican-led Congress looking to ways to reduce federal spending, a new KFF Health Tracking Poll finds that the Medicare and Medicaid programs remain broadly popular, and more people favor more spending on those programs than less spending.

About eight in 10 Americans overall view Medicare (82%) and Medicaid (77%) favorably. This includes majorities across partisans, including most Republicans (75% view Medicare favorably and 63% view Medicaid favorably).

About half (46%) of the public say the federal government doesn’t spend enough on Medicaid, more than twice the share (19%) who say the government spends “too much.” The gap is even larger for Medicare, with half (51%) of the public saying the government doesn’t spend enough compared to 15% who say the government spends too much.

The Affordable Care Act (ACA), sometimes called Obamacare, also remains popular, with nearly two thirds (64%) of the public holding favorable views, though with more of a partisan divide. Most Democrats and independents hold favorable views of the ACA, while about three quarters of Republicans (72%) hold unfavorable views.

Large majorities also say they are “very” or “somewhat” worried that people covered by each of the three programs in the future won’t get the same benefits available today. This includes 81% who say so about Medicare, 72% who say so about Medicaid, and 70% who say so about the ACA marketplaces. Republicans are less worried than other partisans about Medicaid and the ACA.

Ahead of President Trump’s inauguration, the poll also assesses how the public prioritizes 11 potential actions on health that the new administration and Congress could take.

About six in 10 say that boosting price transparency rules (61%) and limiting chemicals in the food supply (58%) are both a “top priority.” This includes majorities of Republicans, independents and Democrats.

During his first administration, President Trump issued federal regulations establishing price transparency requirements for hospitals and insurers, and Robert F. Kennedy Jr., his pick to head the U.S. Department of Health and Human Services, has long advocated against chemicals in food.

In contrast, few among the public rank several other health policies associated with President Trump and his allies as top priorities.

For example, about one in seven say that reducing federal spending on Medicaid (13%) or limiting access to abortion (14%) is a top priority, while much larger shares say each of these “should not be done” (44% and 51%, respectively). Other low-ranking priorities include cutting funding to schools that require students to get vaccinated (15%), encouraging communities not to add fluoride to their water supply (23%), and repealing and replacing the ACA (27%).

Among other health priorities:

• Medicare drug price negotiations. More than half (55%) of the public say it is a top priority to expand the number of prescription drugs subject to Medicare drug price negotiations, including most Democrats (65%) and about half of Republicans (48%). Only 3% say this shouldn’t be done.
• Regulating insurance claim denials. Most people (55%) say more closely regulating insurers’ decisions to approve or deny claims for health services or prescription drugs should be a top priority. This includes most Democrats (61%) and independents (59%), along with nearly half (45%) of Republicans. Overall, just 5% oppose this.
• Enhanced ACA subsidies. About a third (32%) say that extending the expanded financial assistance that helps make ACA marketplace health insurance affordable should be a top priority. This includes half of Democrats (50%) but few Republicans (16%). Only 7% say this shouldn’t be done.

The incoming Trump administration has established a new “Department of Government Efficiency,” or DOGE, charged with developing plans to cut federal spending and reduce regulations.

Most Americans (73%) say that reducing fraud and waste in government health programs would lead to “major” or “minor” reductions in federal spending overall. This includes most Republicans (80%), independents (72%), and Democrats (68%).

At the same time, more than half (55%) of the public also say that reducing fraud and waste would lead to reductions in the benefits that people receive from government health programs. At least half of Republicans (60%), Democrats (55%), and independents (51%) hold this view.

Other findings include:

• Most of the public say the government is not spending enough on the prevention of chronic diseases (60%) or prevention of infectious diseases and preparing for future pandemics (54%). Much smaller shares say the government spends “too much” on each of these.
• More than half (57%) of the public say they expect health care to become less affordable for their families over the next few years. This includes most (54%) Trump voters and half (51%) of Republicans despite the campaign’s emphasis on addressing rising costs, including in health care.

Designed and analyzed by public opinion researchers at KFF. The survey was conducted Jan. 7-14, 2025, online and by telephone among a nationally representative sample of 1,310 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

A new KFF analysis finds that there were 44 million people enrolled in health coverage through the Affordable Care Act’s Marketplaces and its expansion of the Medicaid program in 2024. That represents about 1 in every 6 people under age 65, or 16.4%.  

There was significant variation in ACA enrollment across states, ranging from about 1 in 4 nonelderly people in Louisiana, Oregon, Florida, and New York to fewer than 1 in 10 in Tennessee, Alabama, Wyoming, Kansas, and Wisconsin, according to the analysis.  

With the exception of Florida, the states with the largest ACA-related enrollment as a share of population had adopted the Medicaid expansion, while all five states with the lowest share of enrollment were non-expansion states. (The data includes enrollment in the Basic Health Program, an option offered by some states under the ACA to provide coverage for low-income residents who would otherwise be eligible to obtain coverage through the Marketplace. There were 1.3 million people enrolled in this option in 2024.) 

The new analysis helps illustrate how many people could potentially be affected by the anticipated policy debates in Congress, including whether to allow enhanced ACA Marketplace subsidies to expire this year, whether to reduce the federal share of Medicaid expansion funding, or whether to enact deeper spending cuts to ACA subsidies and Medicaid to help pay for expected tax cuts.   

From 2020 to 2024, total enrollment in ACA programs (Medicaid, Marketplace, and Basic Health Plan) increased by nearly 60%, with the largest increase among Marketplace enrollees, helping to drive the uninsured rate down to historic lows.  The number of Marketplace enrollees increased by 10 million people nationally, almost doubling, over the period, and the number of Medicaid expansion enrollees increased by 6.2 million people. States with the largest increases in enrollment, in percentage terms, included Missouri (243%), Oklahoma (227%), Texas (212%), Mississippi (190%), North Carolina (185%) and Georgia (186%).  

Growth in Marketplace enrollment over the period can be largely attributed to the temporary enhanced subsidies that were made available in 2021, which were extended through 2025. Marketplace enrollment climbed to a new record high in 2025, with nearly 24 million people signing up for plans during the current enrollment period.  Marketplace enrollment was 21.4 million in 2024.

Medicaid expansion enrollment increased due to more states implementing expansion (seven states—Idaho, Missouri, Nebraska, North Carolina, Oklahoma, South Dakota, and Utah—implemented Medicaid expansion during or after 2020) and because of the pause in disenrollments from the pandemic-era continuous enrollment provision. Medicaid expansion enrollment totaled 21.3 million people in 2024. Even with the unwinding of the continuous enrollment provision that was still in play through March 2024, overall enrollment in Medicaid expansion is higher than in 2020.   

The Affordable Care Act (ACA) expanded health insurance coverage by extending Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level (FPL) ($20,783 for a single individual in 2024) and by creating new health insurance Marketplaces through which individuals can purchase private insurance coverage with financial help to afford premiums and cost-sharing. Marketplace subsidies are available for individuals not eligible for Medicaid with incomes above 100% FPL. The Medicaid expansion was originally mandatory for states, but expansion became effectively optional after a Supreme Court decision in 2012. States can opt to provide more affordable coverage to individuals who would otherwise be eligible for Marketplace coverage with incomes between 133% and 200% FPL through a Basic Health Program (BHP). In 2024 Minnesota had a BHP plan, Oregon newly implemented a BHP on July 1, 2024, and New York had a BHP until April 2024 when it transitioned to provide the same coverage to individuals with incomes up to 250% FPL through the state’s Essential Plan (EP).

In total, 2024 ACA enrollment (including Marketplace, Medicaid expansion, and BHP) reached 44 million, or 16.4% of the nonelderly U.S. population. In 2024, Marketplace enrollment hit a new record high, of 21.4 million people (almost double the 11 million people enrolled in 2020), Medicaid expansion enrollment was 21.3 million (a 41% increase from 2020), and BHP enrollment in 2024 was 1.3 million (up from 880,000 in 2020).

Marketplace growth since 2020 can be largely attributed to enhanced subsidies made available by the American Rescue Plan Act (ARPA) in 2021 and renewed through 2025 under the Inflation Reduction Act (IRA). These enhanced subsidies significantly reduced premium payments across the board for ACA Marketplace enrollees – including $0 monthly premiums for enrollees with incomes up to 150% FPL – and made some middle-income people who had previously been priced out of coverage newly eligible for financial assistance. Medicaid expansion enrollment increased due to seven states newly implementing expansion in 2020 or later and adoption of the continuous enrollment provision, a pandemic-era policy that prohibited states from disenrolling people from Medicaid in exchange for enhanced federal funding. Even with the unwinding of the continuous enrollment provision starting April 1, 2023, enrollment in the Medicaid expansion today is higher than it was in 2020.

The uninsured rate hit an historic low in 2023 as coverage through the ACA and Medicaid increased, but these coverage gains may not last for long. If enhanced subsidies are not renewed by Congress and are instead allowed to expire at the end of 2025, ACA enrollee premium payments are expected to increase by over 75% on average, and the Congressional Budget Office (CBO) estimates that the number of people who are uninsured will increase by 3.8 million, on average, in each year over the 2026-2034 period. In addition, potential Congressional efforts to lower the Medicaid expansion match rate from the current 90% rate could reduce federal spending but would shift costs to states and likely result in decisions by many states to terminate coverage. About 4.3 million Medicaid expansion enrollees live in states with some type of trigger law that would end Medicaid expansion or require review of expansion coverage to mitigate increases in state costs if federal funding for the expansion is reduced. There is also potential for deeper cuts to the ACA and Medicaid to help offset increases in the deficit if expiring tax cuts are extended.

While 1 in 6 nonelderly people in the U.S. had some form of ACA coverage in 2024, there was significant variation across states. More than 1 in 5 nonelderly people in seven states (Louisiana, Oregon, Florida, New York, California, New Mexico, and Vermont) and the District of Columbia had ACA coverage through Medicaid expansion, Marketplace, or BHP in 2024. Meanwhile, fewer than 1 in 10 nonelderly residents of five states (Alabama, Kansas, Tennessee, Wisconsin, and Wyoming) had coverage through one of these three ACA programs (Figure 1). With the exception of Florida, the states with the largest ACA enrollment as a share of population had adopted the Medicaid expansion. The five states with the lowest share of enrollment were Medicaid non-expansion states.

From 2020 to 2024, total enrollment in ACA programs (Medicaid expansion, Marketplace, and Basic Health Plan) increased by nearly 60%, with the largest increase among Marketplace enrollees. Growth in Marketplace enrollment from 2020 can be largely attributed to the temporary enhanced subsidies that were made available in 2021 and extended through 2025. Marketplace enrollment growth was greatest among states that have not expanded Medicaid. Meanwhile, Medicaid expansion enrollment similarly increased due to more states implementing expansion (seven states — Idaho, Missouri, Nebraska, North Carolina, Oklahoma, South Dakota, and Utah — implemented Medicaid expansion during or after 2020), and because of the pause in disenrollments from the continuous enrollment provision. Even with the unwinding of the Medicaid continuous enrollment provision that was still in play through March 2024, enrollment in Medicaid expansion is currently higher than it was in 2020. The number of Marketplace enrollees increased by 10 million people nationally, almost doubling, between 2020 and 2024, and the number of Medicaid expansion enrollees increased by 6.2 million people. In 2024, Marketplace consumers made up 49% of all people enrolled in ACA coverage compared to 42% in 2020 (Figure 2).

From 2020 to 2024, the rate of growth in ACA enrollment varied widely by state, more than doubling in some states while changing very little in others. Enrollment across the three ACA programs more than doubled from 2020 to 2024 in twelve states: Missouri (243%), Oklahoma (227%), Texas (212%), Mississippi (190%), North Carolina (185%), Georgia (181%), Tennessee (177%), South Carolina (167%), South Dakota (155%), Alabama (141%), Florida (120%), and Nebraska (113%, Figure 3). Meanwhile, other states saw less than 20% growth over those four years: Washington (19%), Rhode Island (18%), Kentucky (17%), Colorado (17%), the District of Columbia (16%), Montana (14%), New Mexico (11%), and Massachusetts (10%).

Of the ten states with the largest increase in ACA program enrollment from 2020 to 2024, all were won by President Trump in the 2024 election, and none had expanded Medicaid before 2020. In non-expansion states, individuals with incomes between 100% and 138% FPL are eligible for subsidized Marketplace coverage, and with the enhanced subsidies making the coverage more affordable by providing coverage with $0 premiums, more people enrolled. All non-expansion states, except Wisconsin, and all states that adopted Medicaid expansion in 2020 or later, except Idaho, had increases in ACA enrollment that exceeded the national increase of 61%. (Wisconsin Medicaid eligibility extends to 100% FPL so there is no coverage gap.) Meanwhile, many of the states with lower enrollment growth over the last four years have long embraced the ACA (adopting Medicaid expansion early on and creating their own state-based Marketplaces), so they started out with relatively high shares of their populations already enrolled in ACA coverage in 2020 (Table 1).

This analysis was updated on January 9, 2025 to reflect the approval of Hawaii’s waiver.

As of 2019, over 800,000 Medicaid enrollees between the ages of 12 to 64 had a diagnosed stimulant use disorder that was recorded in Medicaid claims data (though this is likely an undercount). Stimulant use disorder—which can involve dependence on cocaine, methamphetamine, or other psychostimulants, like prescription stimulants—can lead to severe physical and psychological complications. Unlike opioid and alcohol use disorders, there are no FDA-approved medications for treatment, limiting treatment options for those affected. A November 2023 report from the Assistant Secretary for Planning and Evaluation (ASPE) included recommendations to expand “contingency management.”

Contingency management is an evidence-based psychosocial intervention that uses motivational incentives, such as vouchers or gift cards, to encourage recovery behaviors like stimulant abstinence and treatment session (e.g., cognitive behavioral therapy, group therapy) attendance. According to the American Society of Addiction Medicine, contingency management is the current evidence-based standard of care for treatment of stimulant use disorder. However, access through most payers, including Medicaid, remains limited. CMS policy only allows states to add contingency management coverage through Medicaid 1115 demonstration waiver authority.

The Biden administration has approved five state contingency management waivers (California, Delaware, Hawaii, Montana, and Washington); two additional state contingency management requests are currently pending federal review. These waivers are primarily for the treatment of stimulant use disorder. It is uncertain if these waivers will be a priority under the next Trump administration. This waiver watch briefly explains what contingency management is and summarizes contingency management 1115 waiver approvals to-date.

What is contingency management?

Contingency management is a treatment for stimulant use disorder that uses incentives (e.g., gift cards or vouchers) to reward patients for meeting treatment goals, such as stimulant abstinence. For instance, a contingency management treatment plan may involve weekly urine drug tests, with immediate rewards for negative results. Contingency management can also be combined with other therapies, such as cognitive behavioral therapy, with incentives tied to participation in treatments like group therapy or counseling sessions. The American Society of Addiction Medicine recognizes contingency management as the current standard of care for stimulant use disorder due its strong evidence base. Currently, there are no medication treatment options available for stimulant use disorder. Contingency management can also be used as a treatment or support for other types of substance use disorders, such as improving adherence to medication for opioid or alcohol use disorders. Although the Department of Veterans Affairs began implementing contingency management over a decade ago, access through most payers, including Medicaid, remains limited.

How are states using Section 1115 waivers to provide contingency management?

In December of 2021, CMS approved the first contingency management waiver in California and has since approved contingency management waivers in four additional states (Delaware, Hawaii, Montana, and Washington). Two states currently have pending contingency management requests (Michigan and Rhode Island). In waiver approvals, CMS clarifies that for the purposes of these demonstrations, motivational incentives do not violate federal rules that prohibit or limit providers from offering incentives to patients, and contingency management is considered a Medicaid-covered item or service based on the available scientific evidence for treating a substance use disorder. Some states, such as Montana and Washington, are using waivers to build upon successful state contingency management pilots that are grant or state funded, or funded using opioid settlement funds. Key waiver approval details include (Table 1):

• Eligibility. All states with current approvals cover contingency management treatment services for people with stimulant use disorder. In some states, contingency management will also be used for people with other types of substance use disorders alongside FDA approved medication-assisted treatment for opioid or alcohol use disorders to improve treatment adherence. CMS notes medication-assisted treatment should be prioritized for opioid and alcohol use disorders.
• Program length. State approvals range from 12-week programs to 64-week programs (based on target population).
• Incentive amounts. Gift cards (e.g., to Walmart or other retailers) begin at $10-$12 and increase with each week the participating beneficiary demonstrates non-use of stimulants but are “reset” back to the base amount if a participant submits a positive sample or has an unexcused absence. (Motivational incentives earned through these programs do not count towards gross countable income for determining Medicaid eligibility).

All waiver approvals include protections such as staff training requirements, incentive restrictions, and protections against fraud and abuse. Waiver special terms and conditions detail the following requirements for all states:

• Providers. Contingency management benefits are to be delivered through behavioral health providers approved by the state. States must conduct provider readiness reviews to ensure that providers are able to offer contingency management benefit in accordance with state standards. Staff providing or overseeing contingency management benefits must participate in contingency management-specific training.
• Incentive restrictions. Restrictions must be placed on incentives so they cannot be used to purchase cannabis, tobacco, alcohol, or lottery tickets.
• Provider fraud and abuse protections. To protect against fraud and abuse, states must set standard incentive amounts (i.e., providers will not have discretion to set these amounts). States also must use secure incentive management tools with safeguards against fraud and abuse that automatically calculate incentive amounts and generate incentives for patients based on drug test results inputted by the coordinator.

Of the 800,000 Medicaid enrollees aged 12 to 64 with a diagnosed stimulant use disorder recorded in Medicaid claims data in 2019, about 22% were residing in states that now have approved 1115 waivers for contingency management services (California, Delaware, Hawaii, Montana, Washington). If the currently pending waivers (Michigan and Rhode Island) are also approved, this coverage could extend to 26% of enrollees with a diagnosed stimulant use disorder. However, these numbers likely underestimate the total number of Medicaid enrollees with a stimulant use disorder, as not all individuals are screened, and diagnoses are not always recorded. Not all individuals with stimulant use disorder in these states will be eligible for or receive contingency management services. In California, 3,255 people received contingency management services from the launch of the program in April 2023 to June 2024.

In January 2025, President-elect Trump will be sworn in with Republican control of Congress and a conservative majority in the Supreme Court, which will potentially provide broad latitude for the adoption of a conservative agenda. Federal policymakers have many levers to make major changes that will shape the access and availability of reproductive health including abortion, contraception and maternity care in ways that could affect the whole nation, even in states where the right to reproductive health care is enshrined by the state constitution. In addition to enacting legislation, presidential executive orders, litigation, regulatory actions, and nominations to the judiciary, cabinet, and other leadership position appointments will all affect policy.

This brief reviews some of the possible actions of the incoming Trump administration and new Congress based on campaign statements, policies implemented by the first Trump administration, and proposals forwarded by allied conservative think tanks and antiabortion advocacy groups. While President-elect Trump has generally said in recent comments that he would leave abortion policy up to states, his statements at times leave open the possibility for federal changes, and he will likely come under pressure from outside groups and Congress to restrict abortion access.

Abortion

Trump takes credit for overturning Roe and has said that states should set their own abortion policy, including banning abortion. As President, he could support additional policies that would result in limits to abortion access in all states, even without enacting a national abortion ban.

Currently, 13 states ban abortion with very few exceptions and several other states limit abortion availability to early in pregnancy. While Trump has said that he would not sign a federal bill banning abortion in all states, there are many levers that an anti-abortion administration can use to severely limit abortion access. Project 2025 and other anti-abortion organizations and policymakers have outlined a clear agenda, with the goal of banning or severely restricting abortion, especially targeting medication abortion given its dominance as a method of abortion and the current FDA policy that allows for the mailing of abortion pills without the need for any in person contact with a clinician.

Abortion Access

Trump has given conflicting statements about whether he would support a national ban that would apply in all states. At times, he has suggested that he would support a nationwide ban at 15 or 16 weeks gestation, but also has said that he would not sign a national ban. He has said that he believes in exceptions for cases of rape, incest, and life of the mother, but has not forwarded a stance on health exceptions. In his recent comments, Trump has said he would leave abortion access up to states.

Enforcing the Comstock Act

Medication abortion pills account for the majority of abortions in the U.S. The Comstock Act is an 1873 anti-vice law banning the mailing of “obscene” matter and articles used to produce abortion. The Biden administration’s Department of Justice determined that the Act only applies when the sender intends for material or drug to be used for an illegal abortion, and because there are legal uses of abortion drugs in every state including to save the life of the pregnant person, there is no way to determine the intent of the sender. However, this analysis does not preclude the Trump administration from interpreting the Comstock Act differently. President-elect Trump’s statements about medication abortion have been inconsistent, at times suggesting he would not block their availability and decline to enforce the Comstock Act. Recently, Trump said he “probably” would not move to restrict medication abortion but added that “things change.” Some Republican leaders, including Vice president-elect Vance and the authors of Project 2025 —the detailed conservative policy treatise that was spearheaded by many former Trump administration leaders – have called for a literal interpretation and enforcement of the Comstock Act to halt the mailing of all abortion medications and supplies to all states. This would impact not only residents of states where abortion is banned or restricted but all states, even those that have a guaranteed right to abortion in their state constitutions.

FDA Review of Mifepristone

The new director of the FDA will have significant influence over drug approvals, restrictions, and the broader agenda and priorities of the FDA. President-elect Trump recently indicated he will probably not restrict access to medication abortion but left room to change his position. Project 2025 and other conservative groups are calling for the FDA to retract its approval of medication abortion pills. Short of reversal, they seek to revert to older FDA protocols and restrictions that would reduce the gestational period for medication abortion pills, prohibit telehealth appointments and access through pharmacies, which were approved after President Biden took office. These issues are at the core of a federal lawsuit against the FDA that has been brought by Republican states, which the Trump administration may not defend and could succeed in front of a conservative Supreme Court.

Project 2025 also calls on the FDA to ease the process for health care providers to report complications resulting from abortion pills to the FDA Adverse Events Reporting System (FAERS). Although it’s not yet clear how the new director will address mifepristone, Trump’s nominee, Dr. Martin Makary, has stated that fetuses feel pain during an abortion between 15 and 22 weeks gestation, despite conclusive evidence by major medical organizations and systematic reviews that find that a human fetus does not have the ability to experience pain at that point in pregnancy.

Pregnancy-Related Emergency Care

Since the Dobbs ruling, there have been numerous cases of deaths and near-death experiences attributed to denials and delays in providing abortion care to people experiencing miscarriages and pregnancy-related emergencies. EMTALA is the federal law that requires hospitals to provide health stabilizing treatment to patients who present to their emergency rooms, and the Biden administration issued guidance reiterating that EMTALA applies to abortion care provided in the cases of pregnancy-related emergencies. The Biden administration defended this policy in an ongoing case, but the Trump administration could withdraw the current guidance and stop defending the Biden administrations’ policy, as recommended by Project 2025, which argues that emergency abortion denials are not a problem.  President-elect Trump has not commented specifically on this issue. While Trump disavowed Project 2025 during the campaign, he has also announced appointments of a number of people tied to the effort since the election.

Coverage under Medicaid and ACA Marketplaces

The Hyde Amendment is a policy attached to the Congressional appropriations bill annually that bars the use of any federal funds for abortion, only allowing exceptions to pay for terminating pregnancies that endanger the life of the pregnant person or that result from rape or incest. While Trump has not spoken about the Hyde Amendment recently, he had earlier pledged to make it permanent law, as advocated by Project 2025. The report also urges policymakers to resurrect an earlier proposed Trump administration policy that would have required enrollees in ACA Marketplace plans to submit two separate payments if they choose a plan that includes abortion coverage.

Data and Research

The Trump administration could exert its influence over research and surveillance on abortion activities across multiple federal agencies. The Project 2025 report addresses abortion-related data collection and research. In particular, the report calls for CDC research on the risks of abortion, abortion survivors, and requiring reporting on the number of abortions from every state (currently voluntary) as a condition of receiving federal Medicaid funds. The plan details the need to collect data on abortion rates across various demographic groups, monitor the number of cases of infants born alive after abortions (which does not happen), abortion harms, and withhold HHS funds from states where abortion remains legal if they do not comply with these requirements. Any new requirement on states as a condition of receiving federal Medicaid funds will likely be challenged in the courts.

The new administration may also curtail scientific research and vaccine development by reinstating a previous Trump administration policy that barred NIH funding for projects that use of tissue and cell lines that are byproducts of abortions. Project 2025 characterizes this as “the destruction of human life” and a major breach of ethics that government should prohibit. It could also be used to build the case for establishing “fetal personhood” arguments that can be used to further embed abortion bans and restrictions.

There are a number of other administrative actions that were passed under President Biden that the Trump administration could revoke, including guidance that reinforced requirements for pharmacies to fulfill their obligation to provide access to reproductive health pharmaceuticals, enforcement of non-discrimination policies for health care providers, and rules that strengthened data privacy to protect those seeking reproductive health care.

Religious Refusals

Trump’s first administration prioritized expanding religious exceptions to the provision or coverage of certain health care services. During his first term, HHS created a Division on Conscience and Religious Freedom and proposed multiple policies that would expand religious exemptions for health care providers and payors. Additionally, CMS invoked the Weldon Amendment and threatened to withhold federal Medicaid dollars from California because of the state’s policy requiring abortion benefits in all state-regulated health plans. The amendment is attached annually to a federal spending bill, and bars HHS funds from going to programs or state and local governments that “discriminate” against plans, providers, or clinicians that refuse to provide, offer referrals for, pay for, or cover abortions.

Misinformation

Short of formally implementing policies, President-elect Trump and his advisors can sow confusion by the information and misinformation that they spread. For example, Trump has repeatedly stated that Democrats support abortion up to and after birth, which is false. Similarly, members of his circle of health care advisors have stated that abortion is “murder,” fetuses can feel pain, and suggested that abortion can cause cancer. All of these statements have been refuted by scientific and medical groups.

Contraception

President-elect Trump could reinstate policies that he implemented in his first term that resulted in the reduced availability of contraceptive care to low-income people through regulatory action that targeted the Title X federal family planning program. The Republican party platform states support for “access to birth control,” but a federal the Right to Contraception Act failed to pass Congress this year, due to opposition or abstention from the vast majority of the Republican Senators, including Vice President-elect Vance. Trump placed multiple restrictions on financing for contraception in his first term.

Title X Federal Family Planning Program

While in office, the Trump administration rewrote the rules governing the federal Title X program, the federal family planning program that supports contraceptive access for people with lower incomes. Title X funds have never been used to pay for abortion services. The Trump administration disqualified family planning clinics from participating in the program if they also offered abortion services (with separate funding); additionally, they prohibited participating clinics from offering referrals to abortion services at other clinics to pregnant patients seeking abortion information. These changes resulted in a steep reduction of the network of clinics receiving federal support from the Title X program. His administration also provided federal family planning funding through Title X funds to crisis pregnancy centers (CPCs) that do not provide contraception, which had been a requirement of the program until that time. While the Biden-Harris administration reversed the Trump administration changes to the program, Project 2025 calls for the restoration of the Trump-era rules, focusing the program on fertility-awareness based methods (FABM), greater support for CPCs, and Congressional passage of a federal law that would prohibit participation from clinics that offer both contraception and abortion services such as Planned Parenthood.

The new Trump administration could either revoke or not enforce the long-standing Title X program’s requirement that Title X-funded clinics provide minors with confidential contraceptive services without parental consent or notification. As a result of recent litigation challenging the rule in Texas where there is a state parental consent requirement for minors, the Biden administration is not enforcing the confidentiality rule in Texas. There are also other states that require parental consent for contraceptive services for minors. The administration could also direct more federal funds toward abstinence education, as they did during Trump’s first term.

Medicaid and Family Planning

Disqualifying Planned Parenthood clinics and other providers that offer both contraception and abortion care from the Medicaid program has long been a priority of some Republican lawmakers and conservative organizations, despite a current federal Medicaid requirement to include all willing providers in the program. Medicaid covers about one in five non-elderly adult women, and is an important source of payment for many family planning providers. For decades, the program has required coverage for contraceptives and other family planning services. In his first term, Trump allowed federal Medicaid funds to be used in a Texas Family Planning Medicaid waiver program that excluded Planned Parenthood and explicitly excluded emergency contraception (EC), which prevents pregnancy after sex by preventing or delaying ovulation. The second Trump administration could approve similar waivers from more states.

For wider-reaching impact, the new Republican Congress could pass legislation stipulating that federal funds to states may not go to entities that provide abortion services, even if the funds are used to pay for non-abortion care. This proposal was included in Republican-sponsored bills that aimed to repeal and replace the ACA in 2017.

Contraceptive Coverage and the ACA

Private insurance coverage for contraceptives and other evidence-based preventive services such as cancer screenings and prenatal care is required under the ACA, but a pending federal lawsuit, Braidwood Management Inc v Becerra, challenges some of these requirements. It is unknown if Trump will fight this case and defend the ACA requirement. Project 2025 calls for the federal government to issue new requirements for contraceptives and other women’s preventive services because of the pending case.  In addition, the Biden-Harris administration recently issued a proposed regulation that would require coverage of over-the-counter contraceptive methods without the need for prescription and would re-define how contraceptives are classified for coverage purposes, potentially expanding the scope of methods that would be required to be covered by plans without cost-sharing. It is unclear if the Biden-Harris administration will finalize the regulation and how Trump will approach the issue.

Maternal Health

During the 2024 campaign, President-elect Trump stated that he would provide full coverage for in vitro fertilization (IVF), which would require Congressional action.

IVF

During the campaign, Trump said that if elected, his administration would provide access to full coverage of IVF services by requiring insurance companies or the government to pay, but he has not provided any details on how this would be funded or operationalized. While Trump says he supports IVF, there is disagreement among conservative circles. The official Republican party platform express support for IVF, but also invokes the 14^th Amendment, which can be used to promote fetal personhood policies that could potentially threaten and criminalize IVF care. Additionally, the Project 2025 authors refer to embryos as “aborted children” and oppose research using embryonic stem cells (which can be derived from the IVF process). In the past year, Republican Senators blocked federal legislation that would have established a federal right and coverage of IVF.

Maternal Mortality and Morbidity

The state of maternal health, particularly pregnancy-related mortality, morbidity, and wide racial and ethnic disparities, remains a major health concern, and at times policymakers across party lines have advanced policies to try and improve maternal health. The pregnancy-related mortality rate in the U.S. is 33.2 per 100,000 live births – the highest of any developed country – resulting in over 1,000 deaths in 2021. The first Trump administration issued a maternal health plan near the end of his term and he signed federal legislation that provided funding for maternal mortality review committees. Doula care has been forwarded as a promising approach to support pregnant people, particularly those who are at risk for adverse maternal and infant birth outcomes. This could be an area that garners some bipartisan interest. The Project 2025 document supports broader access to doulas, with the caveat that no federal funds be used to support training related to abortion care. Some states already cover doula services under Medicaid, but implementation of these benefits has been limited and challenging in many cases.