This brief was updated on June 18 to reflect developments at the 2024 World Health Assembly.

Member states of the World Health Organization (WHO) are in the process of negotiating a new international ‘pandemic agreement’ (also referred to as a ‘pandemic accord’ or ‘pandemic treaty’). Since 2021, member states have held a series of meetings to draft this new agreement. Earlier this year it was expected the process would culminate with a vote on a final text at this year’s World Health Assembly (WHA) in May 2024 but due to a lack of consensus on a number of articles, member states chose to extend the timeline for negotiations until next year, with an expectation that a final vote on any agreement would take place at the May 2025 WHA (potentially earlier if agreement is reached before then).

The Biden administration has supported the concept of an agreement, and has been engaged in negotiations since the process launched. At the same time, several issues have been raised by U.S. policymakers and others, including whether and how the U.S. should ultimately choose to become a party to the agreement. . Given that the negotiating timeline has been extended into next year, the outcome of the U.S. Presidential election this fall is likely to have significant implications for U.S. positions on the agreement and its participation in negotiations in 2025.  If President Trump were to be elected, for example, it is unclear if he would support an agreement, given his criticism of WHO and his move to withdraw from the organization when he was President, as well as his overall “America First” approach to international engagement.

What is the Pandemic Agreement?

The pandemic agreement is a potential international agreement currently being negotiated by the 194 member states of the WHO, including the U.S. Many governments and WHO leadership felt it was necessary to develop a new agreement to address some of the weaknesses in capacities and lack of international cooperation that occurred during the global response to COVID-19. The formal negotiation process (known as the International Negotiating Body, or INB) was launched in 2021. In the view of the WHO Director-General, there would be three key benefits to a new agreement: driving a more equitable global response, helping safeguard national health systems, and enhancing cooperation among member states during pandemics.

According to the latest publicly available draft text (dated 13 March), the overall objective of this new pandemic agreement is to help the world “prevent, prepare for and respond to pandemics.” Among the provisions included (all of which are still being negotiated) are definitions and principles, aspirational goals for improving pandemic preparedness and response capacities, supply chain and logistics, communication, and oversight and implementation for the agreement, with some of the more contested and debated provisions being financing for pandemic preparedness and response, pathogen access and benefit sharing (PABS), intellectual property rights, technology transfer and research and development for pandemic-related products. Also a topic for debate has been the inclusion of the concept of common but differentiated responsibilities (CBDR), meant to address equity concerns by asking richer countries to take on greater obligations to address common goals in pandemic preparedness and response than poorer countries.

What are possible outcomes of the agreement negotiations?

Earlier this year, it was expected there would be a vote on an agreement the 2024 WHA meeting, which occurred in May. However, given the lack of consensus on a number of issues in the agreement, member states decided they needed more time for negotiations and extended the INB’s mandate through May 2025. The next formal INB meeting is scheduled for July 2024, with additional negotiating meetings expected beyond that and into next year. There is an expectation that member states will vote on a final text of any agreement at the WHA in May 2025.

If member states vote in favor, the agreement would be adopted as one of several different types of international legal agreements allowed under the WHO Constitution. Which form it takes is the subject of ongoing negotiation at the INB, but possibilities include a “treaty”, a “regulation” or a “resolution”/”decision,” each of which has specific characteristics and implications (see Table 1).

• Treaty: Proponents of the agreement, and most member states, have supported a “treaty” as the preferred outcome as it is expected to have the greatest influence and broadest potential scope. Indeed, the latest draft of the agreement includes text that indicates adoption and ratification as a treaty (Article 34), but this could change. However, a treaty would have the highest bar to clear in terms of votes needed for approval, subsequent ratification by a minimum number of member states to enter into force, and only would apply to member states that do ratify the treaty.
• Regulation: If the agreement is approved as a “regulation,” in contrast, it would enter into force immediately for all member states (unless they opt-out), but this form could be seen as less influential compared to a treaty and could have some limitations on the issues it can directly address.
• Resolution or Decision: Finally, WHO member states could choose to approve an agreement as a “resolution” or “decision”, which would essentially be a statement of support for certain principles without specific legal or other obligations for member states and would therefore be seen as the weakest and least ambitious form of agreement.

What has been the U.S. engagement with and positions on the agreement so far?

The Biden Administration has been actively participating in the negotiations since the INB was formed in 2021. Co-led by the State Department and the Department of Health and Human Services, the U.S. representatives’ stated goals are to “ensure any agreement will leave all countries better prepared for pandemics, allow data and laboratory samples to be shared more quickly and transparently, and support more equitable global access to drugs, vaccines, and tests during health emergencies.” Earlier this year the U.S. supported completing negotiations and holding a vote on the agreement at this year’s WHA meeting but joined other member states in voting to extend the negotiations until next year given the lack of consensus on several issues in the text. However, Biden Administration officials have stated they are optimistic about reaching consensus eventually, and that the “contours of the agreement are in place”.

With closed-door negotiations still ongoing, information about U.S. positions on different components of the agreement is limited and may be subject to change. Statements from officials indicate U.S. support for the overall principles in the draft agreement, such as the aspirational goals for building pandemic preparedness capacities and calls for international cooperation. U.S. officials also have come out in favor of a some kind of PABS system where countries would commit to share pathogen samples and information, and manufacturers of vaccines, drugs and other pandemic-related products would “set aside a dedicated percentage of production for equitable distribution during pandemics.” In contrast, U.S. representatives have made critical comments about the idea of requiring intellectual property rights on pandemic-related products to be waived on a temporary basis during a pandemic, saying “eliminating intellectual property protections will not effectively improve equitable access during pandemic emergencies, and will in fact harm the systems that have served us well in the past”. While U.S. officials have voiced support for voluntary technology transfer goals in the agreement, they have been critical of including language that requires mandatory technology transfer. At recent INB meetings, U.S. officials have voiced opposition to the common but differentiated responsibilities (CBDR) concept and argued against creating a new pooled funding mechanism for pandemic preparedness and response through the agreement.

What objections are being raised in the U.S. about the agreement, and is there evidence supporting these objections?

Some U.S. policymakers and observers have raised objections to the agreement in part or in full. Below are some of the commonly expressed objections, and available evidence regarding the objections:

• Concerns about U.S. sovereignty and/or ceding authority to WHO. Some Republican members of Congress have expressed concerns that an agreement would threaten U.S. sovereignty and could cede power to WHO. However, regardless of which type of instrument is ultimately adopted, an agreement would not change WHO’s power or member state sovereignty. WHO itself is not to be a party to an agreement, but rather its role is to provide a forum for the negotiations held by member states themselves. The current draft (Article 24) makes this point explicitly, saying the agreement “should not be interpreted” as providing WHO with any authority over domestic laws or policy. There is no mechanism included or possible for punishing member states for not meeting the goals of the agreement. Biden administration representatives involved in the negotiations have similarly stated that an agreement would not provide WHO with “…any authority to direct U.S. health policy or national health emergency response actions.” In addition, governments can choose not to be a party, opt out, or register reservations for any agreement. The U.S. government has regularly submitted reservations to other international agreements regarding federalism and its obligations, including to the WHO-based IHR revision approved in 2005.
• Concerns about financial burden on U.S. taxpayers and/or U.S. companies. Some Republican lawmakers have expressed concerns than an agreement would require U.S. contributions, placing a financial burden on U.S. taxpayers. In addition, some lawmakers and pharmaceutical industry groups have raised concerns that an agreement would require contributions from U.S. pharmaceutical companies involved in producing pandemic-related products (such as tests, treatments, and vaccines), placing an undue financial burden on those companies. At this time, there is no language in the draft agreement text requiring contributions from member states such as the U.S. However, the text does propose (Article 20) a “Coordinating Financial Mechanism” to support global pandemic preparedness efforts, which would include a “pooled fund” drawing from several sources including voluntary contributions from governments. It also includes language (Article 12) creating a system for pathogen access and benefit sharing (PABS), for which manufacturers of pandemic-related products such as pharmaceutical companies may be expected to pay annual contributions (amounts not specified) to support the PABS system and would be expected to provide WHO (or another mechanism for global sharing) a 10% share of their production of relevant diagnostics, therapeutics, or vaccines at no cost plus an additional share (10%) at reduced prices during pandemics. Current draft language (Article 12) also proposes that manufacturers can make further voluntary, non-monetary contributions “such as capacity-building activities, scientific and research collaborations, non-exclusive licensing agreements, arrangements for transfer of technology and know-how.”
• Concerns about intellectual property rights, and implications for U.S. pharmaceutical company innovation and development of pandemic-related products. S. lawmakers from both parties, along with pharmaceutical industry groups, have raised concerns that an agreement could “undermine” intellectual property (IP) rights and pharmaceutical innovation by requiring companies to “give away” IP protections on pandemic-related products they develop, thereby reducing incentives to invest in research and development of such products. At this time, the revised draft text of the agreement does not require companies to give up IP protections. One section (Article 11) recommends countries and companies consider supporting “time-bound waivers of intellectual property rights” in order to speed or scale up manufacturing of pandemic related products but the preamble of the current draft recognizes “protection of intellectual property rights is important for the development of new medical products,” while also recognizing concerns about IP on prices of those products.
• Concerns about transparency of U.S. positions on the agreement provisions and its adoption. Civil society groups and others have raised questions about the transparency of U.S. engagement with the agreement negotiations, and the lack of access to draft negotiating texts. While throughout the process an official draft negotiating text has been released on only a few occasions, this is in large part due to the multiple parallel closed-door negotiations that took place earlier focusing on different sections of the agreement, resulting in a lack of an “interpretable” text given the amount of edits being suggested by member states. In addition, policymakers and others have criticized the U.S. negotiators for not being transparent about whether they will seek ratification of the agreement through the U.S. Senate, allowing a role for Congress in its consideration, or seek to approve an agreement solely through Executive Agreement. While Senate ratification followed by Presidential signature is the formal process by which treaties are ratified under the U.S. Constitution, the U.S. President has the option of acceding to a treaty/agreement through executive action alone, without the advice and consent of the Senate.¹  In fact, the great majority (estimated at over 90%) of all U.S. international legal agreements are approved via executive action rather than formal Senate approval.

A few other concerns have been raised about the agreement, for which there is little evidence. For example, some Republican members of Congress have raised a concern that the agreement would direct U.S. tax dollars to be used to fund abortion overseas. However, there is no evidence – in statements from participating governments, the WHO, or in the text of the draft itself – indicating funds associated with agreement are meant to or could be used in support of abortion, which in any case is not an activity linked to the pandemic preparedness capacity-building that is the subject of the agreement. Further, U.S. law and current policies have long prohibited U.S. foreign assistance from supporting abortion overseas. Another concern raised by some Republicans and other stakeholders is that China has undue influence at WHO and therefore the validity of any agreement negotiated under WHO is compromised. The origin of the agreement can be traced back as an initiative of primarily European member states rather than China, and China’s role has been that of one of many member states rather than a controlling force shaping negotiations.

Looking Ahead

While agreement has been reached on some articles of a draft pandemic agreement, there is also much that remains to be determined in terms of the specific wording and content and indeed whether an agreement will be reached at all. Member states remain engaged in rounds of negotiations and much could change between now and a final version of the agreement. The expectation is that the negotiations will conclude in 2025, and given that U.S. elections will be held in November 2024 there remains some uncertainty about the future of U.S. engagement. This is especially true if President Trump were to be elected, given his prior administration’s history of speaking out against WHO and moving to withdraw the U.S. from WHO membership, as well as his more general “America First” approach to international engagement. With Republican lawmakers and associated groups echoing those calls to withdraw U.S. support for WHO, U.S. engagement with and approval of any future agreement could be very different depending on the 2024 electoral results.

1. For further information on the process and implications of U.S. international treaty adoption, see reports from KFF and Congressional Research Service. ↩︎

Substance use disorders (SUDs), including opioid and alcohol use disorders (OUDs and AUDs), are a major public health issue affecting millions of Americans. SUDs contribute to a growing number of deaths, with alcohol-induced and opioid overdose fatalities rising sharply in recent years, especially during the pandemic. Opioid overdose deaths grew by 63% during the pandemic, to 81,051 in 2022, and alcohol-induced deaths increased by 31%, to 51,244 in the same year. Despite this, SUDs often go undiagnosed, unrecorded and untreated in healthcare settings.

As a dominant payer of behavioral health services, Medicaid can be a lever to expand access to a range of behavioral health services, including treatment for SUD. This analysis examines Medicaid claims data from 2020 to understand clinically-identified rates of SUD (referred to as diagnoses throughout the brief) as well as treatment patterns across SUD services, how treatment rates vary across groups of Medicaid enrollees and states and spending among Medicaid enrollees aged 12-64 who have a diagnosed SUD. Although claims data provide the clearest picture of the use of Medicaid-covered services among enrollees, they may exclude treatment for enrollees in some circumstances, such as when services are provided by Indian Health Services, schools or as part of bundled payment rates (see Methods for more details).

Key takeaways include:

• Claims data show that 7.2% of Medicaid enrollees aged 12-64 have a diagnosed SUD. This may underestimate prevalence of SUDs because screening/referral practices vary and SUD diagnoses often go unrecorded without treatment. For example, data from the 2020 National Survey on Drug Use and Health, shows that 18% of Medicaid enrollees 12-64 have a SUD as NSDUH may capture undiagnosed SUDs. As a result of lower diagnosis rates in claims data, estimates of treatment rates using claims data might appear higher than they really are since they do not account for the total number of enrollees with SUD.
• Nearly three-quarters of those with a diagnosed SUD in claims data used substance use treatment or supportive services in 2020, but there are wide variations across service type. For example, treatment rates for counseling/therapy and medication treatment were higher than other service types. Medication treatments rates are much higher for those diagnosed with OUD (63%) than those with AUD (10%), although medication treatment is recommended for both (see Box 1).
• Enrollees who are Black, Hispanic and Asian as well as youth and young adults have lower overall SUD treatment rates than other groups. Only 4 in 10 Black enrollees with diagnosed OUDs received medication—a treatment rate substantially lower than their White counterparts (nearly 7 in 10). Youth and young adults have lower SUD treatment rates across most SUD services compared to people aged 27 to 44, particularly for medication. About 12% of youth with diagnosed OUD receive medication treatment, compared to 63% overall.
• Substantial state-level variation exists in SUD treatment overall and by specific service. Treatment rates across states show wide variation, with up to 50 percentage point differences in treatment rates for some services.
• Spending for enrollees with an SUD diagnosis is twice as much as those without a SUD (about $1,200 vs. $550 per month on average).

Treatment is key to addressing SUDs and reducing overdoses, deaths and other health or social complications. However, the rates at which Medicaid enrollees receive treatment can vary due to a wide range of factors including the availability and capacity of the behavioral health workforce and treatment facilities, provider participation in Medicaid and Medicaid coverage policies for SUD treatment services. In addition, treatment rates may be affected by the shortage of a diverse and culturally competent workforce as well as personal beliefs and societal stigmas. Understanding variations in treatment rates, particularly in areas or populations with lower rates, can help inform policy options to address SUD.

What are the rates and characteristics of Medicaid enrollees with a diagnosed SUD?

Overall, 7.2% of Medicaid enrollees have a diagnosed SUD in 2020 Medicaid claims data. SUDs can include alcohol or opioid use disorders, but can also include many others such as marijuana, stimulant and hallucinogen use disorders. Because OUD and AUD are the most commonly diagnosed SUDs in Medicaid claims data, and they account for over 80% of all alcohol and drug deaths, this analysis focuses on those conditions specifically as well as SUD overall (which includes all types). Medicaid claims data may underestimate the prevalence of SUDs because screening/referral practices vary and SUD diagnoses often go unrecorded without treatment. For example, data from the 2020 National Survey on Drug Use and Health shows that 18% of Medicaid enrollees 12-64 have a SUD as NSDUH may capture undiagnosed SUDs.

Medicaid enrollees who are White, American Indian and Alaska Native (AIAN), male or older than age 26 have higher rates of diagnosed SUD. These patterns are also generally consistent across OUD and AUD, with one exception. For AUD, diagnosis rates are highest among the oldest age group (45 to 64), whereas diagnosis rates for OUD are highest for people aged 27 to 44 (Figure 1).

What SUD services do Medicaid enrollees diagnosed with SUD receive?

Substance use treatment can be provided in a variety of settings and may include different treatment modalities, medication, and supportive services. For descriptions of these treatments and service types, see Table 1 below. Self-help treatments, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), may also play a role in treatment but are not included in this analysis.

Nationally, approximately three-quarters (74%) of Medicaid enrollees with diagnosed SUDs received treatment or supportive services in 2020. Counseling/therapy, medication and other services (including screening/assessment) have the highest utilization rates. A smaller share (19%) of enrollees diagnosed with SUD receive inpatient or residential services, with the lowest share receiving partial hospitalization or intensive outpatient services (8%). Supportive services are used by about one in seven enrollees (Figure 2). These estimates exclude the use of some services in states where certain providers have the option to bundle services or use a single code to bill for multiple services. They also exclude services for which providers did not directly bill Medicaid, such as those provided through Indian Health Services, free clinics, schools or through self-help groups such as AA and NA.

Medicaid enrollees diagnosed with an OUD generally have higher treatment rates than those with AUD, with the widest variation for medication treatment. Approximately 2.9% of enrollees have a diagnosed OUD and/or 2.6% have a diagnosed AUD (Figure 1). Enrollees diagnosed with OUD tend to have higher treatment rates than those diagnosed with AUD. Variation is most pronounced in medication treatment—with 63% of those with diagnosed OUD receiving medication treatment compared to 10% for AUD (Figure 2). This wide difference in treatment rates exists even though medications for both OUD and AUD are effective and recommended (Box 1). While rates of medication use for AUD are low across payers, progress has been made in increasing OUD medication rates within Medicaid. However, a substantial gap remains—with about one-third of Medicaid enrollees diagnosed with OUD not receiving medication treatment. Several factors may contribute to the OUD medication treatment gap, including difficulty filling buprenorphine prescriptions at pharmacies, low provider prescribing, state and federal policies as well as a number of other factors.

How does use of SUD services vary by demographics and geography?

Among those with a diagnosed SUD, Black, Hispanic and Asian Medicaid enrollees generally receive SUD treatment at lower rates than White enrollees. White enrollees tend to have the highest treatment rates across categories of treatment. Black enrollees with OUD are far less likely to receive recommended medication treatment (4 in 10 compared to nearly 7 in 10 of their White counterparts). Asian enrollees have lower rates of counseling/therapy than White enrollees. While AIAN enrollees have higher medication treatment rates for OUD (relative to many other groups), their rates for other categories, such as counseling/therapy and supportive care, tend to be more variable. Various factors, including low provider cultural competency and fewer treatment options in diverse communities, as well as perceived need for treatment and personal beliefs related to seeking help, may all play a role in the variation of treatment rates across racial and ethnic groups. In addition, limitations in claims data, such as differences in the data quality of race and ethnicity variables, differences in how often SUDs are diagnosed and recorded and potential exclusion of treatment services provided by Indian Health Services can affect observed treatment rates across racial and ethnic groups (see Methods).

Youth and young adults have lower overall SUD treatment rates than older age groups—with treatment rates particularly low for OUD medication treatment among youth. Overall, about 65% of youth and young adult Medicaid enrollees use some type of treatment or service for SUD, compared to 78% for the 27 to 44 age group (Figure 3). Diagnosed SUD is far lower among youth (1.3%) and young adults (5.4%) compared to those aged 27 to 44 (11.2%) (Figure 1). The most notable age-related variation is for medication treatment, with 69% of enrollees aged 27 to 44 receiving medication for OUD, compared to 12% of youth (Figure 3). Medication treatment is currently recommended for some adolescents with OUD. Medication treatment rates for adolescents with AUD are also very low, but medication treatment is not part of current recommendations due to insufficient evidence (Box 1). Males and females use SUD care at similar rates across all types of treatment.

Average utilization of SUD treatment services varies substantially across states. Supportive services, medications for OUD, and inpatient/residential services show particularly wide ranges in treatment rates. Rates for any substance use treatment among diagnosed enrollees range from 53% for the lowest state up to 89% for the highest state. The range across states is particularly pronounced for supportive services and medications for OUD (from 0.1% to 53% for supportive services and 34% to 87% for medication for OUD). Variation is also quite wide for inpatient and counseling services (Figure 4).

Although 74% of enrollees are getting some type of treatment or service, 26% of those diagnosed are not getting any services and there is wide variation across states. In the lowest treatment states, 33% to 47% of diagnosed enrollees do not receive any SUD treatment or support services (Figure 5).

Several states have consistently higher SUD treatment rates across multiple categories. Connecticut, Delaware and Vermont stand out for higher treatment rates across various treatment services. Conversely, there are states with consistently lower treatment rates across categories, including Arkansas, Georgia, Mississippi and Texas (Figure 5). Variation in treatment rates reflects a combination of factors, including differences in states’ coverage policies, state or community efforts to expand access to treatment, treatment infrastructure and workforce, provider participation with Medicaid, and differences in states’ data and the extent to which SUD diagnoses and treatments are captured in the claims data (see Methods).

How does spending for people with SUD compare to overall spending?

Average Medicaid spending is twice as high for enrollees with a SUD diagnosis compared with other enrollees: Over $1,200 per month and less than $550 per month respectively. Notably, spending is highest for those diagnosed with AUD, at approximately $1,400 per month per enrollee. This pattern of higher spending for individuals with a SUD diagnosis is consistent across all age groups (Figure 6).

Why is there variation in SUD treatment rates?

This analysis may overestimate SUD treatment rates and may underestimate certain types of treatment. As a result of lower diagnosis rates in claims data, estimates of treatment rates using claims data might appear higher than they really are, as they don’t account for the total number of enrollees with SUD. Several factors may contribute to underdiagnosis, including limited provider screening/referral practices, insufficient provider training for SUD, reduced healthcare use for some populations, and stigma. Expanding screening beyond traditional settings or increasing care integration could improve identification of those in need of SUD services. Although the data may overstate treatment rates as a whole, some specific treatments may be missing in cases where states allow bundled payments that roll several types of SUD treatment and supportive services into a single code. This may result in lower recorded utilization for some services, particularly supportive services and may also impact counseling/therapy rates.

Among enrollees diagnosed with an SUD, there is notable variation in treatment rates for opioid use disorder compared to alcohol use disorder. Overall OUD treatment rates generally exceed those for AUD, likely reflecting a greater policy focus on addressing the opioid crisis. Differences are most acute for medication, where treatment rates for OUD medication exceed AUD medication rates by more than 6-fold. A few factors may help explain why medications for AUD may be less utilized, relative to OUD, including lower awareness and understanding of medication treatment options for AUD among clinicians and patients, uncertainties about medication effectiveness, and challenges finding psychosocial support. While excessive alcohol use can lead to a number of health issues, it typically lacks the acute mortality risks associated with opioid/fentanyl use, which may reduce the urgency to initiate AUD medication treatment. Treatment patterns may differ for other specific types of SUD.

Availability of substance use treatment infrastructure and workforce may play a role in variation in treatment rates for certain populations. For example, youth and young adults receive SUD treatment at lower rates, potentially due to a shortage of specialized facilities for this population. Some states are addressing treatment needs by adding coverage for services in non-traditional settings, such as schools, though it isn’t clear whether these services will appear in Medicaid claims data. Lower treatment rates for some racial and ethnic groups may contribute to higher overdose death rates. Factors such as low provider cultural competency in care, lack of diversity in the behavioral health workforce, personal beliefs and societal stigmas, perceived need for treatment and limited treatment infrastructure or fewer treatment options in diverse communities may all play a role.

Substantial state-level variation in treatment rates exist and may reflect differences in covered services, workforce, infrastructure, state characteristics and the nature of their Medicaid payment systems and data. States expanded coverage for SUD services in recent years. Access to services not only depends on Medicaid coverage of services and the availability of facilities and beds, but also on the presence of a behavioral health workforce to keep facilities operational and to provide treatment services. Other state Medicaid efforts that have focused on addressing the opioid epidemic and other SUDs include reducing prior authorization barriers for buprenorphine, expanding telehealth access, adding OTC Narcan to formularies and exploring pre-release Medicaid coverage for incarcerated populations. There have been federal efforts to expand access to SUD treatment and the President’s budget includes a number of provisions to further strengthen behavioral health, some of which include expanding funding for the State Opioid Response grant program, expanding behavioral health services in schools and strengthening the behavioral health workforce.

Medicaid unwinding may lead to loss or interruptions in coverage for people who depend on Medicaid for SUD treatment. Coverage interruptions could disrupt enrollee access to necessary treatment and increase the risk of overdose or complications. The recent resumption of Medicaid renewals following a three-year pandemic halt, known as the ‘Medicaid unwinding’,  has led to millions of individuals losing Medicaid coverage. Many people who lose Medicaid have alternative insurance options. However, for those who rely on Medicaid to cover SUD treatment, the loss of Medicaid coverage could disrupt their access to ongoing SUD treatment. Such a loss may disrupt treatment and increase overdose or complication risks.

Appendix

This updated chart collection takes a deep dive into employment data to analyze how jobs and wages in the health sector have changed since the COVID-19 pandemic. Unlike past recessions, health sector employment saw a big drop in early 2020 but has rebounded since. As of February 2024, the health sector added 66,700 jobs over the previous month. Jobs in the health sector are 5.7% higher than in February 2020 (the previous peak), compared to 3.4% in all other sectors.

Still, not all health sector employment trends have recovered. While hospitals and physicians’ offices have returned to pre-pandemic employment levels, industries such as elderly care and skilled nursing care facilities continue to see relatively low employment. Employment in elderly care facilities reached a low of 869,500 in January of 2022 and has been growing slightly since. These facilities had 974,600 employees nationwide in February 2020, and 965,100 in February of 2024—a 1% decrease. Skilled nursing care facilities have seen an 8.3% drop in employment since February of 2020.

The chart collection 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

After months of partisan negotiations and wrangling over the federal budget, Congress finally agreed to spending levels for the remainder of fiscal year 2024, passing an omnibus funding bill on March 23, 2024, that was then signed by President Biden. Tucked into this agreement was a short-term reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR, the U.S. government’s global HIV response), its fourth reauthorization. Widely regarded as one of the most successful global health programs in history and credited with saving millions of lives, PEPFAR had been caught up in the broader U.S. political debate over abortion, which had effectively stalled its reauthorization for the first time in what has otherwise been a long, bipartisan history of support. With the new omnibus bill, PEPFAR has been reauthorized until March 25, 2025, without the inclusion of any controversial provisions or changes related to abortion, sought by some. Still, while this latest step provides the program with some short-term certainty, including signaling bipartisan support (albeit limited), it marks a significant departure from PEPFAR’s past. The outcome of the presidential election and Congressional races determining control of the House and Senate could have significant implications for PEPFAR and the millions of people it serves.

Why PEPFAR Reauthorization Was Stalled

As we explored in an earlier analysis, the latest reauthorization of PEPFAR was drawn into the broader U.S. debate about abortion, even though U.S. law prohibits the use of U.S. foreign assistance, including PEPFAR funding, for abortion. The Biden administration and a wide range of stakeholders had been seeking a five-year, “clean” reauthorization of PEPFAR (an extension of the dates of expiring provisions without any changes to program language or requirements), but abortion was first publicly raised in PEPFAR reauthorization discussions in early May. A coalition of organizations opposed to abortion rights, a conservative think tank’s report, and a member of Congress raised concerns that PEPFAR may be supporting abortion, and they criticized the Biden administration’s support for global sexual and reproductive health and rights, including in PEPFAR’s latest strategy document. There was also a call for Congress to reinstate and apply the “Mexico City policy” to PEPFAR (see box).

In response, PEPFAR stated that it does not provide a platform for abortion, sent official communication to its implementers regarding current law and policy in this area, and revised its strategy to clarify that “sexual and reproductive health services” has a specific meaning in the PEPFAR context and reiterated that “PEPFAR does not fund abortions, consistent with longstanding legal restrictions on the use of foreign assistance funding related to abortion. In addition, no evidence was produced to indicate that PEPFAR supported any prohibited activities. Despite the lack of evidence, however, reauthorization of the program was effectively stalled, and there was uncertainty about whether the program would be reauthorized again.

What the Omnibus Bill Does, and the Difference Between Authorizing and Appropriations Legislation

The omnibus funding bill that passed on March 23, 2024, funds the government for the remainder of the current fiscal year and also included a short-term reauthorization of PEPFAR, marking the fourth time PEPFAR has been reauthorized (although each prior time, it was reauthorized for five-year periods; see Table 1). The language in the bill extended eight time-bound requirements in PEPFAR’s legislation through March 25, 2025 (essentially, halfway through FY 2025). These included seven provisions that had “sunset” or expired at the end of FY 2023 (September 30, 2023) and one provision that would have sunset at the end of FY 2024 (see Table 2). These requirements will “sunset” again if not addressed through a future PEPFAR reauthorization or another legislative vehicle.

More generally, there is an important distinction between “authorizing” and “appropriations” legislation. Authorizing (or reauthorizing) legislation establishes programs and policies, oversight and reporting requirements, and provides guidance to appropriators on funding amounts and conditions. It may include time-bound provisions or may provide no end date for programs to operate, which they can do as long as they are funded. Such legislation can be put forward as a standalone bill or attached to another legislative vehicle, such as appropriations legislation (which is the case with this latest omnibus bill). Appropriations legislation provides budget authority, allowing funding to be provided to an agency or program; absent an authorization (or reauthorization), an appropriations bill can have the effect of allowing the continued operation of an existing program by providing funding. PEPFAR was created in 2003 through authorizing legislation (The Leadership Act), which established the program, its structure, and other program aspects without including any end date or sunsetting of the program (with the exception of some provisions). This means that PEPFAR largely operates under permanent authorities of U.S. law that allow for the program to continue as long as Congress appropriates funding. The omnibus bill also appropriated bilateral funding for PEPFAR at the same level as the prior year.

Looking Ahead

After months of uncertainty surrounding reauthorization, which had created confusion and other challenges for the program, this latest step provides the program with some certainty for the time being. The short-term reauthorization signals a demonstration of bipartisan support, including by Congressional leadership – albeit limited – allowing it to move forward without any changes or controversial provisions around abortion (despite those sought by some). It also extends the program’s authorities past the next presidential election, thereby taking PEPFAR somewhat out of the direct line of sight of presidential politics for now. Finally, the bill also included funding for PEPFAR through the end of FY 2024 (which ends September 30, 2024).

At the same time, this latest development marks a departure from PEPFAR’s long-term history of strong support across party lines through multiple Congresses and administrations. It is possible that there will be more polarized debates over PEPFAR and its funding in the future, particularly as March 2025 and the end of the short-term reauthorization draws closer. Moreover, despite the latest reauthorization extending beyond the election, the outcome itself could have significant consequences for PEPFAR, beyond the debate about reauthorization. If President Trump is elected once again, he will almost certainly reinstate the Mexico City policy to apply to PEPFAR (and global health more generally), and it’s possible its reach could be expanded even further, including to encompass all U.S. foreign aid rather than just global health, as recommended in the Heritage Foundation’s Project 2025 report, intended as a blueprint for a Trump administration. While President Biden’s reelection would mean the Mexico City policy would remain rescinded, Republican control of one or both houses in Congress could result in continued controversy over PEPFAR and abortion. Regardless of electoral outcomes, the ground upon which PEPFAR sits has already shifted, potentially changing the political and programmatic calculus for PEPFAR in the years ahead.

Introduction

Federal funding for HIV has increased significantly over the course of the epidemic, rising from just a few hundred thousand dollars in FY 1982 to about $43.0 billion in FY 2022 for combined domestic and global efforts. However, it represents just a small fraction (<1%) of the overall federal budget of the United States. The majority of HIV funding (57%) in FY 2022, and the driver of growth in the HIV budget over time, was spending on mandatory domestic care and treatment programs through Medicaid and Medicare, as more people are living with HIV in the United States than ever before, new treatments have become available, and the cost of medical care has increased. In addition, greater investments to combat HIV in low and middle-income countries have also contributed to growth, though these have slowed since 2010. More generally, discretionary funding for HIV from Congress has brought only minor increases, primarily due to the Ending the HIV Epidemic effort, and most accounts have not kept pace with inflation over the last decade. In addition to federal funding, states also contribute to HIV care (primarily via their shared contributions to the Medicaid program), as do private insurance plans.

This fact sheet provides an overview of the federal HIV budget, including trends in federal funding between FY 2018 and FY 2022. Appendix A provides a full history of topline federal HIV funding from FY 1981 to FY 2022.Budget Categories

The federal HIV budget can be organized into five broad categories: care & treatment; cash & housing assistance; prevention; research; and global/international. More than two-thirds (67%) of the FY 2022 budget was for domestic care and treatment programs in the U.S.; 8% was for domestic cash/housing assistance; 3% was for domestic HIV prevention; 6% was for domestic HIV research; and 16% was for the global HIV efforts, including funding for international research.

Mandatory/Discretionary

Federal funding is either mandatory or discretionary. Mandatory spending, primarily for entitlement programs (such as Medicaid and Medicare), is determined by eligibility rules, enrollment, and the cost of services for those who are enrolled, and is not dependent on funding from Congress (e.g., if more people are enrolled and/or the cost of services goes up, mandatory spending will also increase). In FY 2022, mandatory spending for HIV accounted for $27.2 billion, or 63%, of the total HIV budget and includes estimated spending levels for: Medicaid, Medicare, Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), programs which provide health coverage and cash assistance. Mandatory spending has accounted for an increasing share of federal funding for HIV, rising from 52% of total HIV funding in FY 2012 to 63% in FY 2022, largely due to growth in Medicare and Medicaid spending.

Discretionary funding levels are determined by Congress each year through the appropriations process and may, or may not, match the full need for or cost of services. The remaining $15.7 billion (37%) of the federal HIV budget in FY 2022 was discretionary. It was slightly higher than the FY18 level ($14.4 billion). Of the FY 2022 amount, $8.7 billion (20% of the overall HIV budget and 55% of discretionary funding) was for domestic programs – prevention, research, housing, and non-mandatory care programs (e.g., the Ryan White HIV/AIDS Program). The remainder, $7.0 billion (16% of the overall budget and 45% of the discretionary component), was for global HIV/AIDS efforts.

The Domestic HIV Budget

The domestic HIV budget includes funding for care, cash/housing assistance, prevention, and research as follows:

Care

The largest component of the federal HIV budget is health care services and treatment for people living with HIV in the U.S., which totaled $28.7 billion in FY 2022 (67% of the total HIV budget and 80% of the domestic share). This represents a 31% increase over the FY 2018 level, primarily due to increased mandatory spending for Medicaid and Medicare. (Medicare and Medicaid spending includes all care for people with HIV, not just HIV related services.) Medicaid is the largest federal funder of HIV care and treatment, followed by Medicare. States also pay a state share of Medicaid funding, including for HIV care, but those amounts are not included in this analysis. The Ryan White HIV/AIDS Program, the largest HIV-specific discretionary grant program in the U.S. and third largest source of federal funding for HIV care (behind Medicaid and Medicare), was funded at $2.5 billion, representing an 8% increase over FY 2018 level. This increase was due to the launch of the Ending the HIV Epidemic initiative, which included new funding for Ryan White and other domestic HIV programs. Ryan White’s AIDS Drug Assistance Program (ADAP), which provides HIV-related medications and insurance coverage to people with HIV, was flat funded in FY 2022 at $900.3 million.

Cash/Housing Assistance

$3.3 billion of the FY 2022 budget for HIV was for cash and housing assistance in the U.S. (8% of the overall budget and 9% of the domestic budget), a 12% increase over the FY 2018 level of $3 billion. This includes mandatory spending estimates for SSI and SSDI, which provide cash assistance to disabled and older individuals with HIV. Housing assistance, through the Housing Opportunities for Persons with AIDS Program (HOPWA), is discretionary and received $450 million in FY 2022, a $75 million (20%) increase over the FY 2018 level.

Prevention

The smallest category of the federal HIV budget is domestic HIV prevention, which totaled $1.1 billion in FY 2022 (about 3% of the overall HIV budget). This includes funding for domestic HIV prevention across multiple agencies, representing a 21% ($184 million) increase over the FY 2018 level. Most prevention funding is provided to the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), which received $987 million in FY 2022, an increase of $201 million over the FY 2018 level. Funding increases for domestic HIV prevention were largely attributed to the EHE Initiative (which included $195 million for CDC in FY 2022).

Research

$2.7 billion (6% of the overall FY 2022 amount and 7% of the domestic budget) in the FY 2022 HIV budget is for domestic HIV research across multiple agencies, slightly higher than the FY 2018 level ($2.6 billion). The National Institutes of Health (NIH), which carries out almost all HIV research, receives $2.6 billion in FY 2022 for domestic HIV research activities (additional amounts used for international HIV research are attributed to the global category, discussed below), slightly higher than in FY 2018 ($2.4 billion).¹ 

The Global HIV Budget

The U.S. government first provided funding to address the global HIV epidemic in 1986. Total funding has increased significantly over time, particularly since the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003. However, since 2010, funding for global HIV efforts through regular appropriations has remained relatively flat.²  Most U.S. funding for global HIV is considered to be part of PEPFAR, including both bilateral HIV efforts (country-to-country funding) as well as contributions to multilateral organizations, including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the Joint United Nations Programme on HIV/AIDS (UNAIDS).³ 

The FY 2022 budget for HIV included $7 billion for the global epidemic – $5.4 billion for bilateral programs, $1.6 billion for the U.S. contribution to the Global Fund, and $50 million for UNAIDS. Global HIV funding amounts to 16% of the overall FY 2022 HIV budget and 45% of discretionary funding. As noted above, funding for global HIV efforts has been relatively flat for over a decade.⁴ 

Bilateral Funding

• Most bilateral HIV funding is channeled to the State Department which received $4.34 billion in FY 2022, a $65 million (2%) increase compared to the FY 2018 level ($4.28 billion), but still $226 million below its peak funding level in FY 2010 ($4.57 billion).
• HIV funding through USAID ($330 million) and CDC ($128.9 million) was flat in FY 2022 compared to the FY 2018 level. Funding for international HIV research activities at NIH was $628.14 million in FY 2022, $63 million above the FY 2018 level.

Multilateral Funding

• Almost all multilateral funding for HIV is provided to the Global Fund, an independent, public-private, multilateral institution which finances HIV, TB, and malaria programs in low- and middle-income countries, and to which the U.S. is its largest contributor. In FY 2022, funding was $1.56 billion for the Global Fund.⁵  The FY 2022 budget for the Global Fund increased by $210 million (16%) compared to FY 2018.
• In FY 2022, funding for UNAIDS, the U.N. system’s coordinating body that serves to help galvanize worldwide attention to AIDS, was $50 million, $5 million (11%) above the FY 2018 level.

Appendix A

1. The NIH does not define HIV research as “domestic” given its broad application. However, for purposes of this analysis, all HIV research funding not designated as “global” is categorized as domestic. ↩︎
2. In FY 2021, Congress provided an additional $3.8 billion in emergency supplemental funding ($250 million for bilateral HIV and $3.5 billion for the Global Fund) to address the global COVID-19 epidemic. These amounts are not included in the figure and table totals. ↩︎
3. In addition, international HIV research activities are supported by the NIH Office of AIDS Research (OAR) through its annual appropriated budget, but these amounts are not considered part of PEPFAR. ↩︎
4. In addition to regular appropriations for global HIV efforts, in FY 2021, in response to the COVID-19 pandemic, Congress appropriated an additional $3.8 billion in emergency supplemental funding, including $250 million for bilateral HIV and $3.5 billion for the Global Fund, to address COVID-19. See, KFF analysis of data from the “American Rescue Plan Act of 2021” (P.L. 117-2). ↩︎
5. Global Fund grants support country projects to fight HIV, tuberculosis, and malaria. Figures used here are not adjusted to represent an estimated “HIV share.” ↩︎

A KFF analysis shows that gross total Medicare spending on Ozempic and other similar drugs has increased dramatically in recent years – even though Medicare is explicitly prohibited by law from covering the drugs for obesity.

That’s because Medicare now covers the drugs, known as GLP-1s, for other medically accepted indications, including to treat diabetes. This week the Centers for Medicare & Medicaid Services (CMS) informed Medicare drug plans that they can cover Wegovy, another drug in this class, for its newly approved use of preventing heart attacks and strokes for people who are obese or overweight.

In 2022, Medicare gross total spending reached $5.7 billion on Ozempic (semaglutide), Rybelsus (semaglutide), and Mounjaro (tirzepatide), all of which it covered for diabetes that year, according to just-released Medicare drug spending data. That was up from $57 million in 2018. (Gross spending does not account for any rebates paid by drug manufacturers to pharmacy benefit managers, which would result in lower net Medicare spending.)

Gross spending on Ozempic alone increased from $2.6 billion in 2021 to $4.6 billion in 2022, pushing it to 6th place among the top-selling drugs in Medicare Part D that year, up from 10th place the year before.

The fact that covering GLP-1s under Medicare Part D for authorized uses is already making a mark on total Part D program spending could be a sign of even higher spending to come as Part D plans are now able to cover Wegovy for its heart health benefits, and if new uses for GLP-1s are approved.

These drugs offer substantial potential health benefits, but the combination of intense demand, new uses, and high prices for these treatments is likely to place tremendous pressure on Medicare spending, Part D plan costs, and premiums for Part D coverage.

This post was updated on March 27, 2024 to include a clarification of the drugs included in the analysis and additional information about rebates.

GLP-1 drugs such as Ozempic, Wegovy, and Mounjaro were initially developed to treat type 2 diabetes, but their effectiveness as anti-obesity medications has generated tremendous excitement and high demand among people who have struggled to lose weight by other means. These drugs are also being tested to treat other conditions, and the FDA has just approved a new use for Wegovy to reduce the risk of adverse cardiovascular events. But the annual cost of these drugs in the US – upwards of $11,000 at recent list prices, though net prices may be lower with rebates negotiated by pharmacy benefit managers – has raised concerns about the fiscal impact of broad coverage of GLP-1 drugs on Medicare, other health insurers, and patients.

Medicare is prohibited under current law from covering drugs used for weight loss, but Medicare Part D plans can cover GLP-1s for their other medically-accepted indications, including to treat diabetes, and now to cut cardiovascular risk based on a recent memo from the Centers for Medicare & Medicaid Services (CMS). While the potential cost of authorizing Medicare coverage of anti-obesity drugs has presented a barrier to enacting legislation to lift the prohibition, covering these drugs under Medicare for authorized uses has already catapulted these drugs to rank among the top-selling drugs covered by Part D, Medicare’s outpatient drug benefit program.

KFF’s analysis of newly released Medicare Part D spending data from CMS shows that total gross Medicare spending on the three newest versions of these diabetes medications that have also been recently approved for weight loss – Ozempic, Rybelsus, and Mounjaro – has skyrocketed in recent years, rising from $57 million in 2018 to $5.7 billion in 2022 (Figure 1). (Gross spending does not account for rebates that result in lower net spending.) Ozempic (semaglutide injection) was approved in December 2017; Rybelsus (semaglutide tablets) was approved in September 2019; and Mounjaro (tirzepatide) was approved in May 2022. As weight loss drugs, semaglutide was approved as Wegovy in 2021 and tirzepatide was approved as Zepbound in 2023. (This analysis does not include all GLP-1s covered by Medicare, only those products with more recent FDA approvals that are also approved as weight loss medications.)

Spending on Ozempic alone increased substantially between 2021 and 2022. Ozempic rose from a 10^th place ranking among the 10 top-selling Part D drugs in 2021, with gross spending of $2.6 billion, to 6^th place in 2022, with spending of $4.6 billion (Figure 2). In total, gross spending under Medicare Part D was $240 billion in 2022; Ozempic accounted for 2% of this amount. This is before taking into account rebates, which Medicare’s actuaries estimated to be 31.5% overall in 2022 but could be as high as 69% for Ozempic, according to one estimate.

Given the relatively high level of gross Medicare Part D spending as of 2022 for the two semaglutide products combined, Ozempic and Rybelsus, it’s possible that Medicare could select this product for drug price negotiation as early as 2025, which would be just over seven years past its earliest FDA approval in late 2017. (For small-molecule drugs like semaglutide, at least seven years must have passed from its FDA approval date to be eligible for selection, and for drugs with multiple FDA approvals, CMS will use the earliest approval date to make this determination.) If that happens, a negotiated Medicare price would be available beginning in 2027. This could lower total Medicare spending on semaglutide products, including Ozempic, Rybelsus, and Wegovy.

The fact that covering GLP-1s under Medicare Part D for authorized uses is already making a mark on total Part D program spending could be a sign of even higher spending to come as Part D plans are now able to cover Wegovy for its heart health benefits, as other uses for GLP-1s are approved, and as policymakers consider legislation that would authorize Medicare to cover obesity drugs. Competition among GLP-1 drugs could have a moderating effect on launch prices and lead to higher rebates negotiated between manufacturers and pharmacy benefit managers. These drugs offer substantial potential health benefits, but the combination of intense demand, new uses, and high prices for these treatments is likely to place tremendous pressure on Medicare spending, Part D plan costs, and premiums for Part D coverage.