Background on PMI

• The U.S. government has been involved in global malaria activities since the 1950s and has been the largest donor to the sector. In 2005, the President’s Malaria Initiative (PMI) was launched to scale up funding and activities to address malaria in the hardest hit African countries, helping to contribute to global success in driving down malaria cases and deaths.
• Still, in 2024, there were 282 million cases of malaria, a life-threatening disease spread to humans by mosquitoes, and 610,000 malaria deaths (the majority of which were among children under age five), a slight increase over the prior year.
• Recent decades have seen major gains in reducing the impact of malaria, and PMI is credited with having helped to save 11.7 million lives and prevent 2.1 billion malaria cases. Indeed, as of 2024, in countries where PMI worked, global efforts supported a 29% decrease in malaria case rates and 48% decline in deaths. In addition, U.S. malaria assistance has been found to bolster the national economies in countries and communities most heavily affected by the disease with an analysis finding that every dollar of U.S. malaria assistance increased GDP in recipient countries nearly six-fold. The introduction of two malaria vaccines in 2021 and 2023 has increased optimism in the potential to further strengthen global malaria control.
• Prior to the dissolution of USAID in 2025, PMI had operated as an interagency initiative led by USAID and implemented in partnership with CDC, focused in 30 countries that account for most of the world’s malaria cases and deaths. It had been overseen by a U.S. Global Malaria Coordinator, a position created by Congress in 2008 to be appointed by the President and based at USAID.
• While the Trump administration has requested significantly less funding for PMI in its budget requests, prior to the start of the Trump administration U.S. funding provided to malaria control efforts and research activities was approximately $1 billion in FY 2024, including about $805 million to PMI and other bilateral global malaria efforts at the State Department and CDC; funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) was $1.65 billion.

Current Status of PMI/Malaria Activities

The following administration actions have had a significant impact on PMI operations:

• Stop-work order: The stop-work order initially froze all PMI programming and services, halting existing PMI activities, including bed net provision, residual spraying and delivery of antimalarial medicines. Because the order halted payments, many implementers had to terminate staff and end some services.
• Limited waiver: Malaria programs received a limited waiver on February 4, 2025, allowing “life-saving services” to continue, including those that “must resume within 30 days to ensure malaria diagnosis and treatment, as well as prevention through distribution of nets and indoor residual spraying targeting highest burden areas…and lifesaving malaria medicines for pregnant women and children”. Even with the waiver, services remained disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: USAID was the main government implementing agency for malaria efforts, obligating almost all bilateral malaria assistance in FY 2023 (96%). Without USAID and most of its staff, PMI’s implementation capacity and operations have been affected. In addition, announcements of reductions at CDC could further affect global malaria efforts.
• Canceled awards: In early 2025, it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 157 included malaria activities, 80% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and move any remaining USAID operations to the State Department, with global health activities, including for malaria, to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. Malaria has been included in most of the agreements signed to date, although there is little information available on activities and funding. A U.S. Malaria Coordinator has yet to be appointed.
• Policy restrictions: In January 2025, the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella known as the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
• Funding: The Trump administration has requested significantly less funding for PMI and other malaria efforts in its budget requests and canceled funding for numerous malaria-related projects and awards. Despite this, Congress has continued to appropriate level funding for malaria control efforts and research activities, reaching approximately $1 billion in FY 2026 (including about $805 million for PMI and other bilateral global malaria efforts at the State Department and CDC). It also appropriated $1.25 billion for the Global Fund in FY 2026.

Impact on PMI Services and Outcomes

• An internal USAID memo from 2025 estimated that an additional 12.5-17.9 million malaria cases and an additional 71,000-166,000 deaths could occur annually if PMI was halted permanently.
• A rapid assessment survey of 108 WHO country offices in 2025 found that of the 64 malaria-endemic countries surveyed, more than half reported moderate or severe disruptions to malaria services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• In early April 2025, almost 30% of planned insecticide treated net (ITN) distribution campaigns were off-track or at risk of being delayed due to funding shortages, and such risks continue today. Several countries also face stock-out risks for key commodities including for rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). Reductions in funding also threaten investments in new and improved malaria prevention, diagnostic, and treatment interventions. Such disruptions pose significant risks, particularly during peak malaria seasons across Africa where seasonal malaria campaigns are needed to protect millions of people. In a court filing challenging the funding freeze, for example, a major U.S. implementer reported that it had to delay the start of anti-malarial campaigns in Africa last year.
• A modeling project estimated that a full year U.S. funding cuts could result in an additional 2.4 million malaria cases among adults and an additional 7.2 million malaria cases among children.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for bilateral malaria efforts and contributions to the Global Fund
• Impact of the PHFFA Policy on U.S. funding and programs
• Impact of U.S. changes to global health programs on health outcomes

Background on U.S. Global Maternal and Child Health (MCH) Efforts

• The U.S. government has been involved in supporting global maternal and child health (MCH) efforts for more than 50 years, as a top donor and provider of technical assistance and other support, helping to contribute to worldwide success in reducing maternal and child mortality.
• Still, in 2024, 4.9 million children under the age of 5 (more than 13,000 every day) died, with the highest rates of under-5 mortality in sub-Saharan Africa. About 260,000 women (or nearly one every two minutes) died during and following pregnancy and childbirth in 2023 – 92% of them in low- and middle-income countries. The majority of these deaths are preventable with proper interventions and access to care.
• Recent decades have seen major gains in preventing maternal and child mortality. Both the number and the rate of children dying before age 5 have fallen by more than 60% since 1990, and almost 100 countries have cut under-five mortality rates by at least two-thirds in that time. From 2000 to 2023, the annual number of maternal deaths worldwide fell by 40%. The U.S. government has contributed significantly to these gains, reporting that it helped to save the lives of more than 9.3 million children and 340,000 women over the past decade alone.
• Prior to its dissolution in 2025, USAID had served as the lead U.S. implementing agency for MCH activities, reaching more than 40 countries, including 25 “high priority” countries, primarily in Africa and southern Asia. The CDC also supported global MCH activities, primarily through immunization and technical assistance to build in-country capacity.
• Prior to the start of the Trump administration, U.S. funding provided to MCH activities was approximately $1.31 billion in FY 2024, including $865.7 million for bilateral MCH activities, $300 million for Gavi and $142 million for UNICEF.

Current Status of U.S. MCH Programs

The following administration actions have had a significant impact on MCH program operations:

• Stop-work order: The stop-work order initially froze all MCH programming and services, halting USAID’s MCH programming, including pre- and post-natal health services and lifesaving maternal health care. Because the order halted payments, many implementers had to terminate staff and end some services.
• Limited waiver: Maternal and child health activities were included in a limited waiver issued by the State Department on February 4, 2025, allowing “life-saving services” to continue, defined as essential services related to the prevention, diagnosis and treatment of severe illnesses and conditions which–if not addressed–lead to mortality in women, newborns, and children under five. Listed in the waiver were antenatal care and post-partum services, essential newborn care, essential immunizations and treatment of acute child illness. Even with the waiver, services remained disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.

• Dissolution of USAID: As the main government implementer of MCH efforts, the dissolution of USAID and loss of most staff significantly affected MCH implementation capacity and operations. In addition, announcements of reductions at CDC could further affect global MCH efforts.
• Canceled awards: In early 2025, it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 266 included MCH activities, 86% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and move any remaining USAID operations to the State Department, with global health activities, including for MCH, to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
• America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. MCH has been included in several of the agreements signed to date, although there is little information available on activities and funding.
• Policy restrictions: In January 2025,the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella known as the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
• Funding: The Trump administration has requested significantly less funding for MCH in its budget requests and canceled or suspended funding for numerous MCH-related projects and awards. This includes rescinding funding for UNICEF; the administration also suspended funding for Gavi unless it met certain conditions (in July 2026 it announced that the withheld funds would be released following discussions with Gavi, and funding has since been provided to the organization). Despite this, Congress has continued to appropriate level funding for these programs, totaling approximately $1.29 billion in FY 2026 (including $845 million for bilateral MCH activities at the State Department and CDC, $300 million for Gavi, and funding for UNICEF “consistent with prior year levels”).

Impact on MCH Services and Outcomes

• An internal USAID memo from 2025 reported that the cessation of USAID programming for MCH would affect services for 16.8 million pregnant women annually, eliminate postnatal care for 11.3 million newborns within the first two days of life, and prevent 14.8 million children under 5 from receiving treatment for pneumonia and diarrhea.
• A rapid assessment survey of 108 WHO country offices in 2025 found that almost half reported moderate or severe disruptions to MCH services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages. WHO also said that funding cuts have “led to facility closures and loss of health workers, while also disrupting supply chains for lifesaving supplies and medicines such as treatments for haemorrhage, pre-eclampsia and malaria – all leading causes of maternal deaths.”
• In addition, several modeling studies have found that cuts in or termination of U.S. MCH funding could result in significant increases in maternal and child deaths and, as a result, the maternal mortality ratio, under 5 mortality rate, and stillbirth rate in coming years.

What to Watch

• Implementation of the America First Global Health Strategy multi-year agreements with countries
• Status of U.S. funding appropriated by Congress for bilateral MCH efforts and contributions to Gavi and UNICEF
• Impact of the PHFFA Policy on U.S. funding and programs
• Impact of U.S. changes to global health programs on health outcomes

Introduction

The 2025 reconciliation law includes new eligibility restrictions for many lawfully present immigrants for federally-funded health programs, including Medicaid and the Children’s Health Insurance Program (CHIP), subsidized Affordable Care Act (ACA) Marketplace, and Medicare coverage. The eligibility restrictions for Medicaid and CHIP become effective October 1, 2026. These restrictions will eliminate eligibility for many groups of lawfully present immigrants, including refugees and asylees without a green card, among others. Under longstanding federal policy, undocumented immigrants already are ineligible for federally funded health coverage. The Congressional Budget Office (CBO) estimates that eligibility restrictions in Medicaid or CHIP will reduce federal spending by $6.2 billion and lead to an additional 100,000 individuals becoming uninsured by 2034.

The Centers for Medicare & Medicaid Services (CMS) released guidance and an implementation toolkit for states to implement the eligibility changes. Beyond those losing coverage because they are no longer eligible, there may also be coverage losses among individuals who remain eligible due to administrative barriers, particularly if they have challenges understanding or responding to notices requesting information and documentation. States will also face increased administrative burdens to implement the changes. This brief provides an overview of implementation of the immigrant eligibility changes and issues to consider for affected individuals and states.

Medicaid Immigrant Eligibility Changes

Starting October 1, 2026, the 2025 reconciliation law will restrict Medicaid and CHIP eligibility to lawful permanent residents (LPRs or “green card” holders), Cuban and Haitian entrants, people residing in the U.S. under Compacts of Free Association (COFA), and lawfully residing children and pregnant immigrants in states that cover them under the Medicaid and/or CHIP option (Table 1). The law will eliminate eligibility for many other groups of lawfully present immigrants, including refugees and asylees without a green card, among others. Prior to the 2025 reconciliation law, undocumented immigrants were already ineligible for Medicaid and CHIP. Additionally, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) limited Medicaid and CHIP eligibility to certain groups of lawfully present immigrants deemed to have a “qualified status” and required many of these groups to wait at least five years before they could enroll even if they met other eligibility criteria. The 2025 reconciliation law does not change the application of PRWORA. Under PRWORA, LPRs are generally subject to the five-year waiting period subject to some exceptions. Cuban and Haitian entrants and COFA migrants are exempt from the waiting period.

States will continue to have the option to provide coverage to lawfully residing children and pregnant people without a five-year wait under the Immigrant Children’s Health Improvement Act (ICHIA) option (also referred to as the CHIPRA 214 option). They will also continue to have the option to provide prenatal care and pregnancy related benefits to targeted low-income children beginning from conception to end of pregnancy (FCEP) regardless of their parent’s immigration status.

Emergency Medicaid and CHIP Health Services Initiative expenditures also are exempt from the new immigrant eligibility restrictions. Emergency Medicaid reimburses hospitals for emergency care they are obligated to provide to individuals who meet other Medicaid eligibility requirements (such as income), but who do not have an eligible immigration status, including undocumented immigrants and lawfully present immigrants who are not eligible for Medicaid or CHIP. CHIP Health Services Initiatives allow states to use a limited portion of CHIP funding to implement public health services aimed at improving the health of low-income children.

Implementation of Immigrant Eligibility Changes

States must redetermine eligibility for all “potentially affected” existing Medicaid enrollees under the new rules by October 1, 2026, and conduct new eligibility determinations consistent with the new rules beginning October 1, 2026. CMS describes potentially affected beneficiaries as those receiving full Medicaid or CHIP benefits who do not have an eligible immigration status under the new rules. CMS indicates that because states vary in the information they keep on file for enrollees, they may have differing ability to identify potentially affected enrollees. As such, some states may need to reverify eligibility for a broader group of noncitizen enrollees.

For potentially affected enrollees, states must first attempt to reverify satisfactory immigration status under the new rules through existing information and automated data matches before contacting the enrollee. States will seek to verify immigration status through the Department of Homeland Security’s (DHS) Systematic Alien Verification for Entitlements (SAVE) program and using Social Security Administration (SSA) databases. If the state verifies satisfactory immigration status, including eligibility under the option for lawfully residing immigrant children or pregnant people, the enrollee will maintain full coverage and should be notified by the state. However, CMS notes that SAVE provides “point in time” verification and does not update past SAVE verification responses when there is a change in immigration status or category. As such, potentially affected beneficiaries may have applied for and been granted adjustment of status to that of an LPR or may have another qualifying immigration status or category that is not reflected in SAVE.

If the state is unable to verify satisfactory immigration status through existing information and data matches, it must request additional information from the enrollee and give the enrollee a reasonable period of time to respond. If the enrollee responds and declares citizenship or a satisfactory immigration status but the state is still unable to verify this information through the SAVE database, the state must provide the enrollee with a 90-day reasonable opportunity period to verify status, during which the state must continue to provide coverage, which may extend beyond October 1, 2026. If the enrollee provides documentation of satisfactory immigration status which is verified with SAVE, the enrollee will retain coverage and should be notified by the state. If the enrollee provides information or documentation that indicates they do not have a satisfactory immigration status or if they do not respond within the specified timeframe, the state must consider whether the enrollee is eligible under the option to cover lawfully residing immigrant children and/or pregnant people (if the state has elected the option), if the enrollee remains eligible for Emergency Medicaid, or if the enrollee is no longer eligible for any coverage. After this determination, the state must provide advance notice, including the right to a Medicaid fair hearing or CHIP review, before terminating coverage or reducing benefits for the enrollee. For Medicaid, states must provide at least ten days advance notice, and, for CHIP, states must provide timely and adequate written notice of the proposed termination and an opportunity for review.

States must update eligibility systems and financial claiming and enrollment data reporting to be consistent with the new eligibility rules. CMS indicates that states must ensure appropriate claiming for individuals eligible only for Emergency Medicaid. It also indicates that they must ensure systems can identify and isolate costs, including administrative costs, related to state-only funded health programs for immigrants so that they do not claim federal matching funds for that coverage. CMS notes that if states cannot make changes to comply with the law, they risk losing federal financial participation (FFP) for Medicaid claims. CMS notes that states may also need to make updates to other materials including Medicaid application and renewal forms; notices to applicants and enrollees; outreach communications to applicants, enrollees, and community-based organizations; and call center scripts, automated messages, and worker guidance. CMS also notes that states should update all presumptive eligibility applications and train providers and caseworkers to correctly assess presumptive eligibility under the new rules. States use presumptive eligibility to expedite Medicaid enrollment for children and pregnant people to access care while their regular application is being processed.

Issues to Consider

Individuals no longer eligible for Medicaid under the new rules will be disenrolled from coverage and left with limited comprehensive coverage options. Individuals in Medicaid may still qualify for Emergency Medicaid but will only be covered for emergency services. Lawfully residing immigrant children and pregnant people will be able to maintain coverage in states that have adopted this option, but coverage varies by state. Subsidized ACA Marketplace coverage will also be limited to lawfully present immigrants who are LPRs, Cuban and Haitian entrants, and people residing in the U.S. under COFA beginning January 1, 2027. Other lawfully present immigrants would be eligible to purchase Marketplace coverage at full cost, but it would likely be unaffordable. Individuals who lose coverage may utilize community health centers for free or sliding-fee scale health care services, but they may have access to a limited scope of services. Some states may provide fully state-funded coverage to those losing Medicaid coverage. However, several states have recently scaled back state-funded coverage programs for immigrants or have reached enrollment caps due to budget pressures and higher than expected demand.

Individuals who remain eligible for Medicaid may experience procedural disenrollments or coverage disruptions due to fear, confusion, or challenges completing verification requirements. Individuals may have difficulty understanding new eligibility rules and whether they remain eligible. Confusion and fears about enrolling in coverage may be amplified by other immigration policies like public charge, new agreements for CMS to share Medicaid data with DHS and Immigration and Customs Enforcement (ICE), and other increased federal immigration enforcement actions. Eligible enrollees may also face challenges submitting required documentation to verify immigration status.

Adequate and accessible outreach, information, and assistance will be key for preventing potential administrative coverage losses. CMS encourages states to use robust, clear, and consistent outreach and communication strategies to help enrollees and applicants understand the upcoming Medicaid eligibility changes and prepare for redetermination and renewals. CMS also suggests that states emphasize notices are time-sensitive, such as by labeling envelopes as such. Outreach through trusted, community-based organizations can help boost awareness among those who will be affected, and community partners may be able to help individuals consider alternatives, including how to access free or low-cost care. Additionally, ensuring linguistic access to information and notices will be key for individuals with limited English proficiency.

Comprehensive information on notices provided to enrollees about Medicaid immigrant eligibility changes is not publicly available across states, but KFF analysis of notices collected from 16 states illustrates there is variation in the information they provide and their accessibility. Most of the examined notices list which groups of lawfully present immigrants remain eligible for coverage, but fewer identify the groups losing coverage. Some states, such as California and Oregon, are transitioning immigrants losing federally funded coverage to state-funded coverage so they include language about how coverage is changing versus potential disenrollment. The examined notices also vary in the information and options provided to enrollees to verify immigration status. Some provide specific lists of acceptable documentation while others request proof of status without identifying specific documentation or direct enrollees to a website or other contact to identify acceptable documentation. Most examined notices offer multiple pathways for enrollees to submit proof of immigration status, including through online accounts or websites, mail, fax, phone, or in-person, while some offer more limited options such as in-person or mail only. The examined notices also vary in the extent to which they advise enrollees about other potential coverage sources, including Emergency Medicaid, and the types of assistance they highlight for enrollees, with some highlighting assisters or legal service organizations as resources. Among the examined notices, only a few were available in another language and/or provided taglines in other languages. However, states may have additional in-language resources that they are providing directly to enrollees that were not publicly available. Reading literacy levels also varied substantially across the examined notices, from a fourth-grade level to a tenth-grade level, as assessed using the SMOG readability calculator, a formula commonly used to evaluate the readability of health-related materials.  

States will face increased administrative burden to conduct outreach, reverify enrollees, and update systems and other materials to reflect new immigrant eligibility rules amid implementation of other Medicaid changes included in the 2025 reconciliation law. States are implementing the immigrant eligibility changes at the same time they are implementing Medicaid work requirements and more frequent eligibility redeterminations for ACA expansion adults. Implementing these changes on a short timeline will increase administrative burdens for states and require state budget investments. States may also make additional investments to expand outreach and to hire and train workers. Enhanced funding is available to support technology systems costs, with a 90% federal match available for design, development, and installation activities and a 75% match available for ongoing operations of CMS approved systems. However, at the same time, states are facing reductions in federal Medicaid funds due to broader changes in the reconciliation law and tightening fiscal conditions due to slowing revenue growth. With regard specifically to immigrants, the law reduces the federal Medicaid matching rate provided to states for Emergency Medicaid services provided to expansion adults who would otherwise be eligible for Medicaid except for their immigration status to the regular matching rate starting October 1, 2026.

States have limited federal guidance to implement the new eligibility rules among certain groups of noncitizens. CMS indicated that it would provide additional guidance related to eligibility changes for individuals enrolled in both Medicare and Medicaid, referred to as dual-eligible individuals, as Medicare immigrant eligibility will be restricted on a different timeline than Medicaid. However, this guidance is not yet available, creating uncertainty for states regarding how Medicaid eligibility changes may interact with Medicare enrollment and cost-sharing assistance for affected individuals. Additionally, many states will need to verify eligibility among noncitizens who are automatically enrolled in Medicaid through Supplemental Security Income (SSI) approval. SSI is a means-tested federal program administered by the SSA that pays monthly cash assistance to people who are unable to work because of a disability and generally qualifies people to receive health coverage through Medicaid, which may be their only source of coverage for long-term services and supports and disability-related services. The 2025 reconciliation law does not change immigrant eligibility rules for SSI, but some immigrants will lose their Medicaid coverage. CMS notes that guidance on the changes the SSA is making to the State Data Exchange (SDX) file to identify eligible noncitizen SSI recipients is forthcoming, but it has not yet been made available.

States may face additional uncertainties due to a lack of CMS guidance. CMS is updating the Transformed-Medicaid Statistical Information System (T-MSIS) Data Guide and plans to provide additional information on T-MSIS data reporting in forthcoming guidance. However, states do not yet have final guidance on how T-MSIS enrollment data submissions will specify enrollee immigration status. CMS also requires all states to submit updated State Plan Amendments (SPAs) with new immigrant eligibility restrictions by December 31, 2026, but has only indicated revised Medicaid and CHIP SPA templates will be forthcoming. Likewise, CMS plans to provide additional technical assistance to states about the potential impact for currently approved Section 1115 waiver demonstrations. CMS also directs states with Medicaid Managed Care programs to evaluate whether the immigrant eligibility changes require capitation rate adjustments or amended rate certifications based on guidance released in September 2025, leaving some actuarial judgments to the states. States will also need to utilize a separate and distinct contract and payment system with any managed care plan they contract with to provide state-funded health coverage services, which may be subject to CMS scrutiny.

Since the start of the second Trump administration, the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. global HIV/AIDS program credited with saving 26 million lives, has undergone significant changes and disruptions as part of a broader foreign aid review. Recent changes include: a temporary stop work order and eventual limits to what services could be continued; the cancellation of numerous PEPFAR awards; and a reorganization of U.S. global health programs, including the launch of a new “America First Global Health Strategy” which is anchored to bilateral agreements with countries, a focus on frontline commodities and services, and a shift from disease-specific programming to a more integrated approach. While modeling estimates and field surveys have provided some information about the potential impact of these changes and disruptions, there has been limited data available for such assessments. PEPFAR’s flagship data platform has historically posted financial and program level results, including from PEPFAR’s Monitoring, Evaluation, and Reporting (MER) system (MER was launched more than a decade ago). However, the data platform was temporarily removed in early 2025 and, when restored, it did not include any program data from FY 2025.   

On April 17, 2026, the State Department released Fiscal Year (FY) 2025 fourth quarter (Q4) MER data (covering the July 1 to September 30, 2025 period), providing the first program-level data made available since the changes of last year. Data for quarters 1-3 were not released, which, per the State Department, is due to data reporting and implementation challenges due to the changes. To provide a snapshot of PEPFAR results after these changes, and given this limitation, this analysis compares PEPFAR’s FY 2025 Q4 results to Q4 results from the previous four fiscal years for a subset of MER indicators. By comparing the same time period for each fiscal year, this approach helps to capture seasonal or other reporting fluctuations that could occur. However, it does not allow for an assessment of disruptions or other changes that may have occurred for the full FY 2025 period.¹

While these data are limited (see box on methodology and data limitations) and provide only a snapshot view, they nevertheless provide insights into understanding how PEPFAR is performing following changes by the Trump administration. Overall, the data show that for some indicators, progress  declined in FY 2025 Q4, including support for prevention services such as pre-exposure prophylaxis (PrEP) and the DREAMS program for adolescent girls and young women, both of which were significantly scaled back by the administration. Reduced access to prevention could lead to increases in new HIV infections in the future. There was also a drop in the number of people with HIV newly enrolled on antiretroviral therapy (ART), an important measure of access. At the same time, without more complete data, there is ambiguity in some of the indicators. For example, both the number of HIV tests conducted and the number testing positive for HIV fell, which could represent an actual decline in new infections or simply a decline in access to testing. Finally, there are areas where progress has been maintained or potentially improved, including the total number of people with HIV on ART, which was stable, and an increase in the number of people living with both HIV and TB who are receiving ART. Going forward, the future of transparent PEPFAR data monitoring and reporting remains uncertain, as it’s unclear whether or not these data updates will continue to be provided given the shift in the U.S. global health strategy to country governments and from disease-specific programming to a more integrated approach.  Without such data, it will be difficult to understand the implications and outcomes of these significant changes. 

Findings

PEPFAR’s Q4 treatment results over the period were mixed. While there were some stable results, particularly for the number of people receiving ART, others dropped, such as those newly enrolled on ART.

• The number of individuals with HIV on antiretroviral therapy (ART) remained relatively stable in FY 2025 Q4 compared to FY 2024 Q4 (20.3 million² compared to 20.4 million) and was higher than the prior fiscal years.
• At the same time, the number newly enrolled on ART in FY 2025 Q4 was the lowest over the period, including 16% lower than FY 2024 Q4 (389.1K compared to 463.5K). This is part of a broader decline over the past five years but one of the steepest year-to-year quarter declines.
• Similarly, the number of pregnant women testing positive for HIV and receiving ART in FY 2025 Q4 was also the lowest over the period, including a 14% decline compared to FY 2024 Q4 (189.3K compared to 220.7K).   
• Finally, individuals on ART with documented viral load suppression (VLS) declined in FY 2025 Q4 by 7% compared to FY 2024 Q4 (14.6 million compared to 15.8 million), but was higher than the prior fiscal years.

HIV testing and diagnostic results were mixed in FY 2025 Q4 compared to FY 2024 Q4, although there were fluctuations over the five-year period.

• Both the number of individuals tested for HIV and the number testing positive fell. The number of individuals tested fell by 17% in FY 2025 Q4 compared to FY 2024 Q4 (19.6 million compared to 23.7 million), though was still higher than in prior years. The number testing positive similarly fell by 15% in FY 2025 Q4 compared to FY 2024 Q4 (380.2K compared to 449.8K), continuing a downward decline and reaching the lowest number over the period.
• Despite these drops, the number of pregnant women attending antenatal care who know their HIV status in FY 2025 Q4 was highest over the period, including a 10% increase compared to FY 2024 Q4 (3.9 million compared to 3.6 million).
• In addition, the number of HIV-exposed infants tested for HIV within the first year decreased in FY 2025 Q4 compared to FY 2024 Q4 (135,000 compared to 162,000) and was the lowest in recent years.

Key PEPFAR prevention results saw large declines, including for PrEP.

• The number of individuals who newly initiated PrEP declined by 41% in FY 2025 Q4 compared to FY 2024 Q4 (388K compared to 659.4K), falling to FY 2022 levels. Access to PrEP with PEPFAR support had increased steadily in recent years, before this drop.
• Also declining significantly was the number of adolescent girls and young women (AGYW) who completed the DREAMS package of prevention services in FY 2025 Q4 compared to FY 2024 Q4 (a drop of 86%, from 1.9 million to 253.4k), its lowest level over the period and less than a quarter of those served in the prior years analyzed. DREAMS had been a major PEPFAR initiative to address the drivers of high HIV incidence rates among AGYW, including gender-based violence, gender inequality, poverty, and inadequate access to education. These broader services are no longer being prioritized by PEPFAR.
• Similarly, the number of children and family members served by the Orphans and Vulnerable Children (OVC) program declined significantly in FY 2025 Q4 compared to FY 2024 Q4 (1.7 million compared to 6.5 million), falling to its lowest level in the last five years, and less than a quarter of those served in Q4 of 2022.
• PEPFAR eliminated reporting on key and priority populations (those who were marginalized or faced particular barriers to HIV services, including men who have sex with men, people in prison, displaced persons or mobile communities, and others) reached with prevention and other interventions. Reporting on voluntary medical male circumcision (VMMC) was also eliminated.

PEPFAR has also provided significant support to address HIV and TB co-infection, and risk of TB among those with HIV. These results were varied.

• The number of individuals living with HIV who know their TB status slightly declined in FY 2025 Q4 compared to FY 2024 Q4 (199k compared to 208.7k) but was higher than prior years.
• The number of individuals living with HIV and TB who are receiving ART declined considerably in FY 2025 Q4, compared to previous fiscal years, including a 33% drop compared to FY 2024 (138.9k compared to 208.1k).
• Similarly, the number of individuals receiving ART who initiated TB prevention therapy declined in FY 2025 Q4 (467.7k compared to 823k), reaching its lowest level over the period and continuing a declining trend. The number for FY 2025 Q4 was a third of the number in FY 2021.
• At the same time, the number of individuals receiving ART who initiated TB treatment increased in FY 2025 Q4 compared to FY 2024 Q4, to its highest level over the period.  

PEPFAR has, for many years, also worked to address the elevated risk of cervical cancer among women living with HIV. While screening for cervical cancer declined, the share receiving treatment for cervical cancer held steady.

• The number of women living with HIV and receiving ART who were screened for cervical cancer declined in FY 2025 Q4 compared to FY 2024 Q4 (806.4K compared to 1.4 million), its lowest level over the period.
• Of the women living with HIV and receiving ART and screened positive for cervical cancer, the share receiving treatment was only slightly below the prior period (89% in FY 2025 Q4 compared to 92% in FY 2024 Q4).

1. One recent analysis, submitted for publication, attempts to address some of these issues by looking at reporting continuity across facilities over time. See, Honermann B, Grimsrud A, Lankiewicz E, Sherwood J, Millett G, The impact of the United States foreign aid freeze on HIV service delivery in PEPFAR-supported countries: a facility-level analysis of 2024–2025 programme data, https://www.medrxiv.org/content/10.64898/2026.04.17.26351143v1. ↩︎
2. The number of individuals on ART in FY 2025 Q4 in the publicly available dataset is 20.3 million. The State Department’s press release about the data cites 20.6 million people. ↩︎

Managed care is the dominant delivery system for Medicaid enrollees with over three-quarters of Medicaid beneficiaries nationally enrolled in comprehensive managed care organizations (MCOs), accounting for half of total Medicaid spending in FY 2024. The 2025 federal budget reconciliation law is expected to create managed care rate setting challenges for states as the Medicaid provisions impacting enrollment and spending, including program financing changes, work requirements, and more frequent eligibility redeterminations for expansion adults, are rolled out. These changes can create uncertainty about enrollment and acuity as states and their actuaries develop capitation rates. Amid this uncertainty, executives from Elevance Health said during a July earnings call that they were exiting DC’s Medicaid market and expect to exit additional markets. Since then, Louisiana announced an Elevance Health plan will exit at the end of 2026. While MCO entries and exits in specific states or markets are not uncommon, decisions by Elevance Health and the other large, multi-state parent firms about overall participation in Medicaid markets could have broad implications for states, enrollees, and providers, given their large share of national MCO enrollment. This policy watch examines recent and anticipated managed care rate setting challenges and the potential implications of MCO exits.

States and plans expect to face new rate setting challenges with implementation of the 2025 reconciliation law. MCOs are at financial risk for services covered under their contracts, receiving a per member per month “capitation” payment for these services. Capitation rates must be actuarially sound and are applied prospectively, typically for a 12-month rating period, regardless of changes in health care costs or utilization.  States may use a variety of risk mitigation tools to ensure payments are not too high or too low, including risk sharing arrangements, risk and acuity adjustments, medical loss ratios (MLR), or incentive and withhold arrangements. In KFF’s 2025 Medicaid budget survey, many states reported anticipating challenges with projecting the potential impacts of federal policy changes, including work requirements and more frequent eligibility redeterminations for expansion adults, which have implications for member enrollment and acuity (or health risk) on average. Provider tax and state directed payment caps and reductions are also expected to create managed care plan rate setting challenges.

These expected rate setting challenges follow a period of rate setting uncertainty that occurred as millions of people were disenrolled during the “unwinding” of the pandemic-era Medicaid continuous enrollment provision. Higher member risk and utilization patterns began to emerge by late 2023, and many states sought federal approval to adjust rates to address these shifts in FY 2024 and FY 2025. KFF analysis of National Association of Insurance Commissioners (NAIC) data shows that the average medical loss ratio (percentage of premium revenue spent on medical care costs) for the Medicaid managed care market increased from 88% in 2023 to 91% in 2024, implying a potential decrease in profitability. This was the highest average MLR seen across health insurance markets (including group, individual, and Medicare Advantage) in 2024 and the highest average MLR observed for the Medicaid managed care market in the past decade.

Overall changes in acuity from work requirements are uncertain. During unwinding, plans experienced an increase in member acuity as enrollment declined and remaining enrollees had higher health care needs and costs. Some multi-state parent firms have indicated publicly on earnings calls that they do not expect acuity changes going forward to be as significant (as the shift that occurred during / post unwinding), in part, because work requirement and more frequent eligibility determination policies target expansion adults (and not all Medicaid populations).

Five for-profit, publicly traded companies – Centene, Elevance Health, UnitedHealth Group, Molina, and Aetna/CVS –account for nearly half of all Medicaid MCO enrollment (Figure 1). These firms have a wide geographic reach in Medicaid, each operating MCOs in 13 or more of the 42 MCO states.

In July 2026, executives from Elevance Health said they expect to exit Medicaid markets over the next 12 to 18 months. During its second quarter 2026 earnings call, executives reported they are reviewing their overall Medicaid portfolio and will plan to exit markets “where the economics don't support sustainable performance.” Elevance executives did not identify the states/markets where the exits are expected to occur beyond DC, or how many enrollees could be affected. Elevance offers MCOs in 21 states (Figure 2). Its share of Medicaid MCO enrollment varies across states, ranging from 6% to 44% (as of July 2024). Medicaid members account for about 20% of the firm’s overall medical membership. Executives reported that while acuity shifts are moderating and rates are increasingly reflecting experience, utilization remains elevated compared to pre-pandemic levels. The firm expects its full-year 2026 Medicaid operating margin to be -1.75% (the percentage of revenue left over after paying operating costs) and to see incremental acuity pressure in 2027.

Wellpoint DC (an Elevance subsidiary) exited DC’s Medicaid program effective August 1, 2026, following a “mutual agreement” with the DC Department of Health Care Finance.  (Wellpoint DC (formerly Amerigroup) was awarded its most recent DC Medicaid MCO contract in 2022 following a contested procurement process.) The contract, which began in April 2023, was scheduled to run through January 2028. In September 2026, the Louisiana Department of Health announced that Elevance’s Healthy Blue plan will exit the state’s Medicaid program after its contract expires at the end of 2026.

The other large for-profit parent firms (Centene, Molina, UnitedHealth, and CVS) did not discuss planning to exit Medicaid markets during their public Q2 2026 earnings calls. However, Centene reportedly plans to exit Arkansas’ Medicaid expansion program in 2027, which uses Medicaid funds to purchase Marketplace coverage, citing current funding challenges.

Managed care plan exits could lead to short-term administrative burden for providers and care disruptions for enrollees. For providers, plan transitions may create additional administrative burden at a time when many may also be helping enrollees navigate new eligibility requirements. Plan transitions may also cause disruptions in care for enrollees if their providers are now out-of-network or they need to obtain new prior authorizations. Disruptions may have more severe consequences for certain populations, such as enrollees who are pregnant or those in the middle of a course of treatment. Federal rules include requirements related to managed care enrollment processes and continuity of care. States can also set requirements for plan transitions through managed care contracts. For example, states can require exiting plans to provide notice of the exit within specified timeframes and to transfer data to the state and the plans receiving their enrollees. States can also set requirements for the receiving plans such as honoring prior authorizations granted by an enrollee’s previous plan and allowing enrollees to see out-of-network providers for a certain period after the transition.

Managed care plan exits could also have longer-term effects on the market.  For example, plan exits could result in higher quality of care in the market if lower performing plans exit. At the same time, fewer plans in an (already concentrated) market could reduce competition which could have negative effects on cost, quality, and/or access. State procurement policies and program design can be used to help promote competition and quality in the market by influencing the number and mix of plans in a state.

Introduction

As of 2024, approximately 28.5 million people in the United States ages five and older have limited English proficiency (LEP). The federal government defines people with LEP as those who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English (also described as speaking English “less than very well”). Individuals with LEP disproportionately experience gaps in health insurance coverage and poor health outcomes, in part, due to language access barriers. Because people of color are more likely than White people to have LEP, these barriers can also exacerbate racial and ethnic disparities in health and health care.

This brief provides an overview of individuals ages five and older who have LEP and their health coverage based on KFF analysis of the 2024 American Community Survey (ACS) data. It also incorporates data on health and access to health care for adults with LEP from the 2023 KFF Survey on Racism, Discrimination, and Health. For this analysis, individuals with LEP are identified as those who are ages five or older who report speaking a language other than English at home and speaking English less than “very well.” Key takeaways include:

• People with LEP are a large and growing population who are disproportionately likely to be Hispanic or Asian and largely concentrated in a handful of states. The number of people ages five and older with LEP in the U.S. has grown from 25.7 million or 8% of the population as of 2021 to 28.5 million or 9% of the population as of 2024. Most individuals with LEP are Hispanic or Asian, with Hispanic people accounting for nearly two thirds (62%) of the population with LEP and Asian people accounting for about one in five (21%) of people with LEP. More than half of people with LEP live in just four states: California (23%), Texas (13%), Florida (11%), and New York (9%).
• Individuals with LEP are more than three times as likely to be uninsured as people who are English proficient (23% vs. 7%). This higher uninsured rate is driven by a lower rate of private coverage, likely reflecting that people with LEP are disproportionately employed in jobs and industries less likely to offer health coverage and may face challenges affording it when it is available. Medicaid coverage helps fill this gap in private coverage but does not fully offset the difference.
• Adults with LEP report worse access to care and health outcomes than those who are English proficient. Adults with LEP are less likely than English proficient adults to say they had a health care visit in the past three years (86% vs. 95%) and are less likely to have a usual source of care other than the emergency room (74% vs. 88%). Additionally, about a third (34%) of adults with LEP describe their physical health as “fair” or “poor” compared to about one in five (19%) English proficient adults. Language barriers can make it difficult for people with LEP to access and navigate the health care system. For example, they may face difficulty understanding eligibility rules, completing applications, scheduling appointments, filling out provider forms, communicating with medical office staff, or understanding care or medication instructions.
• Federal policy changes will likely make it harder for people with LEP to access health coverage and care. The Trump Administration designated English as the official language of the U.S., which may reduce availability of language access services. People with LEP may also face challenges navigating new Medicaid requirements  under the 2025 reconciliation law, including work requirements and more frequent redeterminations, particularly if outreach and communications are not available in their language. People with LEP who are lawfully present immigrants may face compounding challenges associated with reduced eligibility for coverage under the same law and increased immigration-related fears in the current environment.Amid these challenges, key protections remain in place for people with LEP. Title VI of the Civil Rights Act and Section 1557 of the Affordable Care Act prohibit discrimination against people based on their national origin, including their ability to communicate in English, and require many health care entities, including Medicaid agencies, to provide meaningful access to people with LEP.

Overview of People With LEP

As of 2024, 28.5 million, or nearly one in ten (9%) people ages five or older living in the United States had LEP, up from 25.7 million, or 8%, in 2021. Most people with LEP are Hispanic and Spanish speaking. Hispanic people account for over six in ten (62%) people with LEP, and Asian people account for about one in five (21%), with other racial and ethnic groups accounting for smaller shares (Figure 1). Reflecting the racial and ethnic distribution of this population, Spanish is the primary language spoken among people with LEP (63%), followed by Chinese (7%), Vietnamese (3%), Tagalog (2%), and Arabic (2%).

While people with LEP live across the country, more than half (56%) live in four states: California (23%), Texas (13%), Florida (11%), and New York (9%) (Figure 2). The remaining 44% of the population is spread across the rest of the country.

Asian and Hispanic adults have the highest rates of LEP across racial and ethnic groups. About three in ten Asian (30%) and Hispanic (29%) people have LEP, while rates are lower for Native Hawaiian or Pacific Islander (NHPI) (11%), Black (3%), American Indian or Alaska Native (AIAN) (3%), and White people (2%).

Noncitizen immigrants are more likely than citizens to report having LEP. Nearly six in ten (59%) noncitizen immigrants have LEP compared to over a third (37%) of naturalized citizens and just 2% of U.S.- born citizens (Figure 4).

LEP is also more common among people with lower household incomes. Over one in ten (13%) of individuals in households with an annual income below $40,000 have LEP compared to 7% in households with an annual income of $90,000 or more (Figure 5).

The share of people with LEP varies widely across states, from less than 1% in West Virginia to 18% in California. Other states with relatively high rates of people with LEP include New York (15%), New Jersey (14%), Florida (14%), Texas (13%), Nevada (12%), Hawaii (11%), and Massachusetts (10%) (Figure 6). This pattern likely reflects the high shares of Hispanic and Asian people and immigrants residing in those states.

Health Coverage Among People with LEP

Individuals with LEP are more than three times as likely to be uninsured as English proficient individuals (23% vs. 7%). This higher uninsured rate is driven by a lower rate of private coverage. Just over a third (37%) of people with LEP have private coverage, compared to nearly six in ten (57%) English proficient individuals, a gap that likely reflects a disproportionate share of people with LEP working in lower income jobs and industries that are less likely to offer employer-sponsored coverage. While Medicaid coverage helps offset some of this gap, it does not fully close it, leaving people with LEP more likely to be uninsured than those who are English proficient (Figure 7).

Among people with LEP, Hispanic (31%) and Black people (19%) have higher uninsured rates than their White counterparts (12%) (Figure 8). In contrast, Asian people with LEP have the highest rate of private coverage (50%) and the lowest uninsured rate (7%) across racial and ethnic groups. These racial and ethnic patterns are consistent with patterns among the broader population and likely reflect a variety of factors, including differences in access to private coverage, income, and citizenship status.

Challenges and Barriers to Care for People with LEP

Adults with LEP report more limited access to and use of care and worse health outcomes than their English proficient counterparts. KFF survey data from 2023 show that adults with LEP are less likely than those who are English proficient to have had a health care visit in the past three years (86% vs. 95%) and less likely to have a usual source of care other than the emergency room (74% vs. 88%). Additionally, over one in three (34%) of adults with LEP report their physical health as fair or poor compared to 19% of their English proficient counterparts (Figure 9).Other research also shows that people with LEP experience worse access to care and health outcomes than those who are English proficient. A 2024 review found that people with LEP are less likely to access ambulatory care, hospitalization, cancer screening, chronic care management, and general health care. Having LEP is associated with lower use of preventative health care and with health behaviors linked to chronic disease. Beyond utilization, a 2025 review of cardiovascular disease found that patients with LEP and heart failure were more likely to have higher rates of hospital readmission and emergency care than English proficient patients with heart failure. Having LEP is also associated with lower rates of cancer screening.

Language barriers can make it difficult for people with LEP to enroll in health coverage even if they are eligible. Enrolling in health coverage requires understanding plan options, eligibility rules, and application processes, which can be challenging without translation options. A 2022 KFF analysis of state Medicaid websites found that 39 of 50 states offered a translated Medicaid PDF application online, but only 13 of those states offered a translation in a language other than Spanish, leaving most people with LEP who speak other languages with no in-language option. Call centers, often a primary resource for enrollees, showed similar gaps. While 40 states offered assistance in another language, 31 only offered it in Spanish. Gaps in language access can also make it more difficult for people to stay enrolled in coverage even if they are eligible. For example, among Medicaid enrollees in Illinois, individuals with LEP were over five times more likely than English proficient enrollees to be disenrolled, with 85% reporting they needed help reading their renewal notice, and 94% saying they needed help completing the enrollment form.

Beyond enrollment in health coverage, language barriers can create challenges to accessing care. KFF 2023 survey data show that about half (50%) of adults with LEP said they encountered at least one language barrier in a health care setting in the past three years, including difficulty filling out forms for a provider (34%), communicating with medical office staff (33%), understanding a provider’s instructions (30%), filling a prescription or understanding how to use it (27%), or scheduling a medical appointment (25%) (Figure 10). Language barriers also shape the quality of care people receive. For example, adults with LEP are less likely than English proficient adults to report that their provider explained things in a way they could understand (81% vs. 89%), spent enough time with them during visits (68% vs. 76%), and involved them in decision making about their care (63% vs. 82%).

Having access to providers who speak a preferred language helps reduce barriers and improve health care experiences for people with LEP. KFF 2023 survey data show that adults with LEP who reported having at least half of their visits with a language concordant provider were less likely to experience a language barrier (40% vs. 60%).  They were also more likely to report their provider understood and respected their cultural values (87% vs. 76%) and more likely to report their provider asked about their social needs, like housing, food, or transportation, than their counterparts who had fewer than half of their visits with a language concordant provider (29% vs. 15%) (Figure 11).

Federal policy changes will likely make it harder for people with LEP to access health coverage and care. The Trump Administration designated English as the official language of the U.S., which may lead to a reduction in availability in language access services. Additionally, people with LEP may face challenges navigating new Medicaid requirements that will be implemented under the 2025 reconciliation law, including work requirements and more frequent eligibility redeterminations, particularly if outreach and communications are not available in their language. People with LEP who are lawfully present immigrants may also face compounding challenges associated with reduced eligibility for coverage under the 2025 reconciliation law and increased immigration-related fears in the current environment. Amid these challenges, key protections remain in place for people with LEP. Title VI of the Civil Rights Act and Section 1557 of the Affordable Care Act prohibit discrimination against people based on their national origin, including their ability to communicate in English. Under these laws, certain entities, including Medicaid agencies and health care providers, must take reasonable steps to provide meaningful access to applicants and enrollees with LEP. However, the Trump Administration issued new regulations eliminating disparate impact, a discriminatory effect without intentional discrimination, as a basis for claims under Title VI of the Civil Rights Act, which may limit enforcement under this avenue, though Section 1557 requirements remain in place.