Background on the U.S. and the Global Fund

• The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is an independent public-private, multilateral financing entity created in 2002. It raises and pools resources from multiple donors to address HIV, TB, and malaria and in turn, invests more than $5 billion per year in more than 100 low- and middle-income countries.
• The Global Fund reports that it has helped to save 65 million lives and reduce the combined death rate of its three focus diseases by 61% since 2002. With its support, in 2023, 25 million people were on antiretroviral therapy, 7.1 million were treated for TB, and 227 million mosquito nets had been distributed.
• The U.S. government was instrumental in the creation of the Global Fund and is its largest donor, accounting for 33% of its funding. It also plays a significant role in governance and oversight of the Global Fund.
• Only LMICs whose most recent Gross National Income (GNI) per capita is below a certain threshold and meet disease burden criteria are eligible for Global Fund assistance. Countries are required to co-finance by investing in health systems and HIV, TB, and malaria national responses. To date, 11 countries have graduated from Global Fund support.
• The Global Fund is considered the “multilateral component” of PEPFAR, as well as U.S. bilateral efforts focused on malaria and TB, complementing and extending the reach of U.S. programs to many more countries. It also works differently thanS. bilateral health programs; unlike the U.S., it has no in-country presence and does not implement programs, instead providing financial assistance based on technical evaluations of country-led proposals. It also plays an important market shaping role through pooled procurement, driving down prices of health products, accelerating innovation and adoption of new products, and promoting quality standards, among other strategies.
• U.S. participation in the Global Fund is authorized in the legislation that created PEPFAR, as a permanent part of U.S. law. Other parts of the authorization are time-bound, including several related to the Global Fund such as a requirement that U.S. contributions to the Global Fund cannot exceed 33% of all contributions, used to limit U.S. funding and leverage support from other donors. Because PEPFAR’s current authorization expired on March 25, 2025, this requirement is not in place.
• The Global Fund replenishes funding every three years, through “pledging conferences.” Its last replenishment, hosted by the U.S. in 2022, generated $15.7 billion in pledges for the 2023-2025 period, including a pledge of $6 billion from the U.S. The next replenishment, for the 2026-2028 period, is scheduled for later this year, for which the Global Fund is seeking $18 billion, which it estimates would save an additional 23 million lives by 2029, and reduce mortality by 64% compared to 2023.

Current Status of U.S. Support for the Global Fund

• Funding: In FY 2024, U.S. funding for the Global Fund was $1.65 billion. The FY 2025 Continuing Resolution that passed in March included level funding for the Global Fund of $1.65 billion. The administration’s FY 2026 budget request does not specify an amount for the Global Fund but did include parameters for ongoing U.S. contributions (final appropriation levels are determined by Congress).
• U.S. Representation at the Global Fund Board: The U.S. also plays a role in the Global Fund’s governance and oversight, holding one of twenty Board seats and currently sitting on two Board committees.
• PEPFAR Reauthorization: While PEPFAR and U.S. participation in the Global Fund are permanently authorized in U.S. law, eight time-bound provisions expired on March 25, 2025, four of which pertain to the Global Fund. In addition to the 33% limit on U.S. contributions, the other provisions also served to direct or place limits on U.S. Global Fund contributions.
• Foreign aid review/freeze: While the actions taken by the administration to implement the executive order calling for a 90-day foreign aid review (which has been extended for 30 days) have thus far not been applied to the Global Fund, or other multilateral institutions, the Global Fund relies on PEPFAR and other U.S. implementers, as well as U.S. government staff and expertise, to assist countries in delivering services. As such, the disruption of that work has affected some Global Fund efforts as well. For example, a partnership announced last year between the Global Fund and PEPFAR to provide long-acting injectable PrEP to more than two million people (once approved by the FDA and recommended by the WHO), is now in jeopardy, as the administration has prohibited the provision of PrEP (except in limited cases). The Global Fund also recently announced that, due to significant service disruptions and funding uncertainty, it may seek to reprioritize investments to preserve the continuity of essential health services and ensure access to lifesaving interventions.
• International organizations review: A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, is currently underway. Per the order, the purpose of the review is to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed”.

What to Watch

• Results of foreign aid and international organization reviews: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), and the outcome of the review of international organizations is expected later this year. It is unknown whether there will be any recommendations related to U.S. support for or engagement with the Global Fund, and how or if Congress will respond to any such recommendations.
• PEPFAR reauthorization and lapsed legislative requirements: It is unknown if Congress will seek to reauthorize PEPFAR, which could afford it an opportunity to extend the time-bound provisions that apply to the Global Fund. It could also use another legislative vehicle to do so. Even without these requirements in place, the administration could still choose to follow them.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health. While the request does not specify a funding amount for the Global Fund, it states that “Should the Administration decide to provide contributions to the Global Fund in FY 2026, it would ensure the United States is only contributing its fair share by leveraging $1 from the United States for every $4 from other donors, instead of the current $1:$2 matching pledge, up to a total amount of $2.4 billion over three years.” Final appropriation amounts for FY 2026 will be determined by Congress.
• Replenishment. The Global Fund’s upcoming pledging conference later this year will be an important moment for the organization in determining its budget for the next five years.

Background on U.S. Global Health Security Efforts

• The U.S. has supported global health security (GHS) and pandemic preparedness efforts for decades through funding and technical support provided to low- and middle-income countries (as well as support for multilateral efforts). This has included the development of formal GHS partnerships with other countries, starting with 17 in 2014 and rising to more than 50 in 2024, with programs focused in particular in countries at risk for emerging diseases.
• GHS efforts are designed to help countries and regions build capacities needed to prevent avoidable outbreaks, detect infectious disease threats early, and reduce the impacts of epidemics and pandemics through rapid and effective responses.
• Specific activities include: improving surveillance and laboratory systems, reducing the risks of animal to human disease exposures, training epidemiologists and other workers, and fostering better biosafety and biosecurity practices.
• Multiple U.S. agencies, coordinated by the National Security Council (NSC), are involved in these efforts including USAID, CDC, the Department of Defense (DoD), the State Department, HHS, and USDA. The first U.S. GHS Strategy, providing overall guidance across the government, was released by the first Trump administration. The Biden administration released an updated Strategy in 2024.
• The FY 2025 Continuing Resolution passed in March included level funding of $993 million for GHS programs at USAID and CDC. At times, Congress has also provided additional, time-limited emergency funding when outbreaks occur, such as for Ebola in 2014-2015, Zika in 2016, and most recently for the COVID-19 starting in 2020. The administration’s FY 2026 budget request includes $493.2 million for GHS, a decrease of $500 million (final appropriation levels are determined by Congress).
• U.S. investments in GHS have led to measurable increases in capacity, including improvement in 9 of 15 technical areas between 2018 and 2023 in countries with which it has formal GHS partnerships, and reductions in average outbreak response times.

Current Status of U.S. Global Health Security Programs

The following administration actions have had a significant impact on U.S. GHS programs:

• Funding freeze/stop-work order: The stop-work order initially froze all USAID-based GHS programming and services. As a result, many GHS implementing partners let staff go. Some USAID-supported GHS activities in progress were interrupted, such as funding for transport of samples and phone plans for contact tracers.
• Limited waiver: Some GHS activities were included in a limited waiver issued by the State Department on February 4 allowing “life-saving services” to continue, including: rapid emergency response to immediate infectious disease outbreaks, focused on pathogens with pandemic potential and those that pose a national security risk to U.S. citizens (e.g., mpox and H5N1), including detection, prevention, and containment efforts and supply of medical countermeasures. Even with the waiver, services remain disrupted and implementers have faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: Earlier this year, USAID had about 50 staff supporting international outbreak response efforts alone, a number which dropped to six in recent weeks – and even those staff face uncertain futures given USAID has been dissolved. This means many GHS partners have lost points of contact and technical support, in addition to the loss of funding. Recent announcements of reductions at the CDC could further affect GHS capacity.
• DoD GHS programs are also targeted for cuts, with potentially up to 75% of staff to be let go along with reductions in funding.
• Reorganization of foreign assistance. The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities (including its GHS work) to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, including to relocate GHSD within the Department.
• GHS Strategy. The administration announced that it has withdrawn the GHS strategy, stating that it would replace it as soon as possible. However, no timeline has been provided, leaving questions about coordination across the government, particularly in the event of a major health threat and given the reorganization and reduction of global health programs already underway.

Impact on GHS Services and Outcomes

• The combination of Administration actions described above is likely to lead to more challenging and inefficient communication and coordination across U.S. agencies and with partners, contributing to slower responses to emerging health threats, greater impacts in communities in partner countries, and increased risk of importation of threatening diseases into the U.S.
• Experts estimate there is about a 50% chance we’ll see another pandemic at least as dangerous as COVID-19 in the next 25 years, with risk of disease emergence highest in the least prepared countries.
• The health impacts of poorly controlled outbreaks can be severe. An internal USAID memo reported that the risk of losing USAID GHS programs alone could result in more than 28,000 new cases of dangerous infectious diseases such as Ebola and Marburg every year.
• Emerging diseases can result in major economic and social costs, even small-scale outbreaks.
  • The original (2003) SARS outbreak resulted in an estimated $30 billion in economic losses (over $3 million per case) from reduced commerce, travel and trade.
  • The 2014-2015 West Africa Ebola epidemic resulted in an estimated $53 billion in economic losses. A single Ebola patient in New York in 2014 cost the city’s Health Department $4.3 million in response measures.
  • Measles outbreaks in the U.S., initiated through importation from other countries, can lead to significant costs; a recent study from Washington state found that a 71-case measles outbreak led to societal costs of $3.4 million, or almost $50,000 per case.
• Epidemics that become pandemics have massive economic costs, as recently experienced with COVID-19 which cost the U.S. alone an estimated at $16 trillion– a number four times as large as the lost economic output from the financial crisis of 2008.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), including for GHS. It is unknown whether it will recommend any further changes to current efforts, including further reductions, and how or if Congress will respond to its recommendations.
• Reorganization. The proposed dissolution of USAID and integration of remaining USAID GHS activities into GHSD raises questions, including how these activities will be integrated with existing GHSD functions and whether new capacities will be needed. GHSD has historically focused on coordination and diplomatic roles in support of GHS rather than the in-country implementation roles that USAID and CDC have led on. A new GHS Strategy may address these issues.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $500 million reduction for GHS. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas from the rescission, although global health security was not listed among those program areas.

Background on PMI

• The U.S. government has been involved in global malaria activities since the 1950s. In 2005, the President’s Malaria Initiative (PMI) was launched to scale up efforts to address malaria in the hardest hit African countries.
• Malaria is a life-threatening disease that is spread to humans by mosquitoes. There are approximately 263 million malaria cases and 600,000 deaths each year; the majority of malaria deaths are among children under age five.
• PMI is credited with helping to save 11.7 million lives and prevent 2.1 billion malaria cases since 2000. Indeed, since 2006, in countries where PMI works, global efforts have supported a 29% decrease in malaria case rates and a 48% decline in deaths. The introduction of two malaria vaccines in 2021 and 2023, respectively, has increased optimism in the potential to further strengthen global malaria control.
• The FY 2025 Continuing Resolution that passed in March included level funding for PMI and other malaria activities at USAID and CDC of $805 million (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria). The U.S. has been the top donor government to malaria efforts, through PMI and contributions to the Global Fund.  The administration’s FY 2026 budget request includes $424 million for malaria, a decrease of $381 million (final appropriation levels are determined by Congress).
• 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, PMI is an interagency initiative led by USAID in partnership with CDC. Efforts have been focused in 30 countries that account for 90% of the world’s malaria cases and deaths.

Current Status of PMI

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

• Funding freeze/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 let go of thousands of staff and end some services.
• Limited waiver: Malaria programs received a limited waiver on February 4 allowing “life-saving services” to continue, defined as those services 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 remain disrupted and implementers have 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 has been affected. In addition, recent announcements of reductions at CDC could further affect global malaria efforts.
• Canceled awards: It was recently reported that the administration has canceled 86% of all USAID awards. KFF analysis finds 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 has not stopped the government from canceling awards.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities 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.

Impact on PMI Services and Outcomes

• An internal USAID memo reported 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 recent modeling study found that PMI could help to avert almost 15 million malaria cases and 107,000 deaths in 2025, gains that would be threatened by the foreign aid freeze, cancelations of projects, and uncertainty of funding.
• A recent rapid assessment survey of 108 WHO country offices 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.
• As of early April 2025, almost 30% of planned insecticide treated net (ITN) distribution campaigns, designed to reach 425 million people, were off-track or at risk of being delayed due to funding shortages. Countries also face limited supply of key commodities including six countries with only a 3-month supply of malaria rapid diagnostic tests (RDTs) and five countries with only a 3-month supply of artemisinin-based combination therapy (ACT). Reductions in funding also threaten investments in new and improved malaria prevention, diagnostic, and treatment interventions.
• The timing of these disruptions poses significant risks for malaria efforts given that malaria season has begun in much of Africa, requiring the need for seasonal malaria campaigns to protect millions of people. In a court filing challenging the funding freeze, for example, a major U.S. implementer reported that it had already had to delay the start of anti-malarial campaigns in Africa.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), including for PMI. It is unknown whether it will recommend any further changes to PMI, including further reductions, and how or if Congress will respond to its recommendations.
• Leadership. At this time, no U.S. Malaria Coordinator has been appointed, and it is unclear, given the dissolution of USAID, what the leadership structure will be going forward.
• Reorganization. The proposed permanent dissolution of USAID and integration of any remaining USAID global health activities into GHSD, including for malaria, raises several questions, including whether additional capacities will be provided to allow for the management and implementation of PMI and these other health programs at the State Department.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $381 million reduction for malaria. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas, including malaria, from the rescission.

Background on U.S. Global Health Programs

• Historically, U.S. global health programs have been overseen and managed by three main federal departments and agencies: the State Department, USAID, and CDC.
  • The State Department is home to the Bureau of Global Health Security and Diplomacy (GHSD), which leads and oversees PEPFAR (which receives direct appropriations from Congress) as well as global health security. Because the State Department is not an implementing agency, it has transferred most PEPFAR funding to USAID and CDC.
  • USAID, an independent agency established by Congress, had housed and managed most other U.S. bilateral global health programs, including TB, malaria, maternal and child health, and nutrition, receiving direct appropriations from Congress for these efforts. It also managed more than half of PEPFAR’s funding, through State department transfers and direct appropriations from Congress.
  • CDC has global programs for HIV, TB, polio, and global health security, which receive direct Congressional appropriations and also manages and implements PEPFAR funding transferred by State and USAID.
• To carry out global health programs, federal agencies fund other organizations, including non-profits, foreign governments, and international and multilateral health organizations, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and Gavi.
• U.S. funding for global health, across multiple federal agencies and for bilateral and multilateral programs, including global health research, totaled $12.4 billion in FY 2025.

Current Status of U.S. Global Health Programs

The following administration actions have or are likely to have a significant impact on the structure and operations of U.S global health programs:

• Funding freeze/stop-work order: The stop-work order, as part of the foreign aid review, initially froze all bilateral global health programming and services, halting existing work in the field (it was not applied to the Global Fund or Gavi). Because it halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited waivers: Certain bilateral global health programs received waivers to allow “life-saving services” to continue, including a limited set of PEPFAR services and TB, malaria, maternal and child health, nutrition and infectious disease outbreak response Even with these waivers, services remain disrupted, and implementers have faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: Because USAID was the main implementing agency for global health efforts, its dissolution and loss of most of its staff have reduced program implementation capacity and operations. Announcements of reductions at CDC could further affect global health efforts.
• Cancelled awards: It was recently reported that the administration has canceled 86% of USAID awards. Of these, KFF analysis identified 770 global health awards, 80% of which were listed as terminated, totaling $12.7 billion in unobligated funding.
• Other executive orders and actions: In addition to the foreign aid review, several other orders and actions have or will likely affect global health, including: a review of international organization participation, the reinstatement of the Mexico City Policy and withholding of UNFPA funding, and withdrawal from the World Health Organization.
• Proposed reorganization: The administration has also announced plans for restructuring or reducing global health efforts as follows:
  • On March 28, Secretary of State Rubio announced that the State Department and USAID had notified Congress of their intent to “restructure certain Department bureaus and offices that would implement programs and functions realigned from USAID” as follows:
    • Proposing legislation to abolish USAID as an independent agency.
    • Separating almost all USAID personnel from federal service within the current fiscal year.
    • Requesting funding in the FY 2026 budget for remaining programs previously implemented by USAID.
    • Identifying USAID programs that “continue to advance the Administration’s foreign policy objectives,” including a subset of global health activities to be transferred to GHSD. These include programs that help reduce health disparities, deliver lifesaving vaccines, promote maternal and child health, and control malaria, TB, and other diseases. The State Department notes that these programs are already coordinated with GHSD, GHSD has expertise to manage them, and integration would result in synergies and allow GHSD to more effectively manage supply chains. The notification also indicates that the Department anticipates making investments to support integration.
  • On April 22, Secretary Rubio announced a reorganization of the State Department to “empower the Department from the ground up, from the bureaus to the embassies”, including removing redundant offices and non-statutory programs that are “misaligned with America’s core national interests.” The reorganization would move GHSD from reporting to the Secretary of State to reporting to the Undersecretary for Economic Growth, Energy, and the Environment. On May 29, the State Department notified Congress with further details, including that GHSD would  be reorganized to include three major divisions: Health Programs (with the Office of Health Programs and the Office of Program Transition and Supply Chain), Health Policy and Diplomacy (with the Office of Health Diplomacy and the Office of Program Planning and Evaluation), and Global Health Security (with the Office of Outbreak Detection and Response).
  • The administration’s FY 2026 budget request proposes to eliminate the CDC’s Center for Global Health, keeping only funding for global health security activities.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), but it is unknown whether it will recommend further changes to global health programs, or how or if Congress will respond to its recommendations. Results of the review of international organizations are expected later this year.
• Reorganization: While the reorganization of U.S. global health programs is well underway, there are still many questions about what programs will be maintained and how they will be managed, implemented and monitored, particularly given the significant reductions in federal staff as well as of health care workers more broadly who have been affected by U.S. cuts.
• Leadership: Several leadership positions have yet to be announced, including the U.S. Global AIDS Coordinator (which requires Senate confirmation), the U.S. Malaria Coordinator, and others. Whether the administration will choose to nominate or appoint people to these positions is not yet known.
• Funding/President’s budget request: The administration’s FY 2026 budget request includes a $6.2 billion reduction in funding for global health and proposes to eliminate several funding lines. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of $400 million in FY 2025 Funding for PEPFAR and $500 million in FY 2025 funding for other global health programs. Congress voted to amend the package, exempting PEPFAR funding as well as funding for maternal and child health, TB, malaria, and nutrition from the rescission, although $500 million in family planning and other programs will be rescinded.
• Congressional oversight: As budget and reorganization proposals and requests continue to circulate, members of Congress could choose to exert their own authority, including seeking further clarification and information about the potential impacts of proposed changes.

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, helping to contribute to worldwide success in reducing maternal and child mortality.
• Still, in 2023, 8 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 half since 1990, and over 90 countries have cut under-five mortality rates by at least two-thirds. 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.
• The FY 2025 Continuing Resolution that passed in March included level funding for bilateral MCH activities at USAID and CDC of $845 million (and level funding for multilateral contributions to Gavi and UNICEF). The U.S. has been the top donor government to MCH activities in the world. The administration’s FY 2026 budget request does not include any funding for bilateral maternal and child efforts (final appropriation levels are determined by Congress).
• USAID has 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 supports global MCH activities, primarily through immunization and technical assistance to build in-country capacity.

Current Status of U.S. MCH Programs

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

• Funding freeze/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 let go of thousands of 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 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 remain disrupted and implementers have 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 have significantly affected MCH implementation capacity and operations. In addition, recent announcements of reductions at CDC could further affect global MCH efforts.
• Canceled awards: It was recently reported that the administration has canceled 86% of all USAID awards. KFF analysis finds 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 has not stopped the government from canceling awards.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities 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.

Impact on MCH Services and Outcomes

• An internal USAID memo 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 recent rapid assessment survey of 108 WHO country offices 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 has 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.”
• A recent modeling study found that cessation of U.S. MCH funding would reverse the long trend of decline in maternal and child deaths and stillbirths, with the maternal mortality ratio, under 5 mortality rate, and stillbirth rate increasing by 29%, 23%, and 13% respectively by 2040. This would result in an additional 7.9 million child deaths, 510,000 maternal deaths and 1.8 million additional stillbirths.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), including for MCH. It is unknown whether it will recommend any further changes to MCH efforts, including further reductions, and how or if Congress will respond to its recommendations.
• Reorganization. The proposed permanent dissolution of USAID and integration of any remaining USAID global health activities, including for MCH, into GHSD, raises several questions, including whether additional capacities will be provided to allow for the management and implementation of MCH and these other health programs at the State Department.
• Funding/Budget Request:  The administration’s FY 2026 budget request includes significant reductions in funding for global health, and does not include funding for bilateral maternal and child health efforts. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas, including maternal and child health, from the rescission.

Background on U.S. Global Tuberculosis (TB) Efforts

• The U.S. government has been involved in global TB activities for decades and began ramping up its efforts in the late 1990s when a global TB program was created at USAID.
• TB, an infectious disease caused by bacteria, causes more deaths than any other infectious agent worldwide, including 25 million people who died in 2023, and is among the 10 leading causes of death worldwide. TB is the leading cause of death among people with HIV.
• U.S. government efforts have contributed significantly to improving TB health outcomes, including helping to save the lives of more than 58 million since 2000 and contributing to a 9% decline in TB-related mortality between 2019 and 2023 in USAID TB priority countries.
• The FY 2025 Continuing Resolution that passed in March included level funding for bilateral TB activities at USAID and CDC of $406 million (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria). The U.S. has been the top donor government to TB efforts, through its bilateral funding and contributions to the Global Fund. The administration’s FY 2026 budget request includes $178 million for TB, a decrease of $228 million (final appropriation levels are determined by Congress).
• USAID has served as the lead implementing agency for U.S. TB efforts, focusing on 24 priority countries – with activities in 50 (including at least 20 of the 30 high burden countries) – to support prevention, detection, and treatment of TB, including drug-resistant TB. The Centers for Disease Control and Prevention (CDC) also carries out global TB efforts and the State Department’s Bureau of Global Health Security and Diplomacy (GHSD), which oversees PEPFAR, leads U.S. efforts to address TB-HIV co-infection.

Current Status of U.S. Global TB Efforts

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

• Funding freeze/stop-work order: The stop-work order initially froze all bilateral TB programming and services, halting existing work in the field. Because it halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited waiver: Some TB activities were included in a limited waiver issued by the State Department on February 4 allowing “life-saving services” to continue, which are defined as “Essential screening, testing, and treatment for tuberculosis (TB) and drug resistant TB (DR-TB) including provision and monitoring of laboratory services, drug susceptibility testing, clinical visits, dispensing of essential medicines to avert near-term mortality and spread of infection.” HIV/TB activities were also allowed under PEPFAR’s limited waiver. Even with the waivers, services remain disrupted and implementers have faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: As the main government implementer of TB efforts, the dissolution of USAID and loss of most staff have significantly affected TB program implementation capacity and operations. In addition, recent announcements of reductions at CDC could further affect global TB efforts.
• Canceled awards: It was recently reported that the administration has canceled 86% of all USAID awards. KFF analysis finds that of the 770 global health awards identified, 162 included TB activities, 79% 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 has not stopped the government from canceling awards.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities 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.

Impact on Global TB Services and Outcomes

• An internal USAID memo reported that the cessation of USAID’s TB control programs would increase global TB incidence by 28-32% and have a similar effect on new cases of multi-drug-resistant TB.
• According to WHO, the 30 highest TB-burden countries have already reported that U.S. funding withdrawals are affecting services, including the loss of thousands of health workers, and disruptions of the drug supply chain and laboratory services.
• A recent rapid assessment survey of 108 WHO country offices found that approximately 40% reported moderate or severe disruptions to TB services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• Analysis of the impact in South Africa estimated that the loss of TB funding could result in 580,000 fewer people being tested for TB and 35,000 fewer people receiving TB treatment in 2025.
• A recent modeling study found that U.S. TB program cuts could result in as many as 10.7 million new TB cases and 2.2 million additional TB deaths in 26 high-burden countries by 2030. Researchers concluded that the “loss of U.S. funding endangers global TB control.”
• Another modeling study found that cessation of U.S. TB funding could result in almost 69 million additional TB cases and 2.2 million additional TB deaths by 2040.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review, including for TB. It is unknown whether it will recommend any changes to TB efforts, including further reductions, and how or if Congress will respond to its recommendations.
• Reorganization. The proposed permanent dissolution of USAID and integration of any remaining USAID global health activities, including for TB, into GHSD, raises several questions, including whether additional capacities will be provided to allow for the management and implementation of TB and these other health programs at the State Department.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $228 million reduction for TB. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas, including TB, from the rescission.

Background on PEPFAR

• The President’s Emergency Plan for AIDS Relief (PEPFAR), first authorized in 2003, is the largest commitment by any nation to address a single disease, working in more than 50 countries.
• PEPFAR is credited with having saved 26 million lives and enabling 7.8 million babies to be born without HIV infection. Studies have also found that PEPFAR funding is associated with several “spillover” effects including significant reductions in all-cause mortality, increases in childhood immunizations and in GDP growth, and retention of children in school.
• PEPFAR has been reauthorized by Congress four times, most recently in March 2024 for one year. Although that authorization expired on March 25, 2025, PEPFAR is a permanent part of U.S. law and, other than a set of eight time-bound provisions, continues as long as Congress appropriates funding.
• The FY 2025 Continuing Resolution that passed in March included level funding for PEPFAR’s bilateral programming at USAID, State, and CDC, and DoD of $4.85 billion (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNAIDS). The U.S. has been the top donor government to HIV efforts, through PEPFAR and contributions to the Global Fund.  The administration’s FY 2026 budget request includes $2.9 billion for bilateral PEPFAR activities, a decrease of $1.9 billion (final appropriation levels are determined by Congress).
• PEPFAR is overseen by a U.S. Global AIDS Coordinator, a Senate-confirmed position appointed by the President and holding the rank of ambassador, at the State Department’s Bureau of Global Health Security and Diplomacy (GHSD). GHSD coordinates its implementation through other government agencies (primarily USAID and CDC) and with implementing partners, civil society, and recipient countries.

Current Status of PEPFAR

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

• Funding freeze/stop-work order: The stop-work order initially froze all PEPFAR programming and services, halting existing work in the field, including provision of antiretroviral therapy. Because it halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited Waiver: PEPFAR received a limited waiver on February 1 (with additional information on February 6), allowing it to continue “life-saving HIV services”. However, the waiver only permits certain activities: HIV treatment and care, prevention of mother-to-child transmission (PMTCT), pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women, and HIV testing. Other services, including PrEP for anyone else (including those already on PrEP) and HIV prevention more generally, as well as programming for orphans and vulnerable children, are not permitted. Even with the waiver, implementers have faced challenges in getting permission to resume HIV programming and difficulties in getting paid.
• Dissolution of USAID: USAID was the main government implementing agency for PEPFAR, obligating 60% of its bilateral assistance in FY 2023. Without USAID and most of its staff, PEPFAR’s implementation capacity has been affected. In addition, recent announcements of reductions at CDC, PEPFAR’s second largest implementing agency (obligating 37% in FY 2023), could further affect PEPFAR.
• Canceled awards: It was recently reported that the administration has canceled 86% of all USAID awards. KFF analysis finds that of the 770 global health awards identified, 379 included HIV activities, 71% of which were terminated, including several HIV treatment awards as well as most HIV prevention.
• 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 has not stopped the government from canceling awards.
• Reorganization. The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities to be integrated into GHSD. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, including to relocate GHSD within the Department.

Impact on PEPFAR Services and Outcomes

Numerous reports have documented the impacts of these actions on services and outcomes:

• A survey of PEPFAR recipients conducted in the first week of the stop-work order (January 24-28) found that more than 60% had laid off staff, 36% had completely closed down, and 86% reported that clients would lose access to HIV treatment within one month if the freeze was not lifted.
• A market assessment in PEPFAR countries found that, as of March 2025: HIV testing had been disrupted in 10 countries and there was a risk of ARV stocks outs in 8 countries, viral load testing stockouts in 13 countries, and oral PrEP medication stock-outs in in 4 countries. Even where HIV commodities were in country warehouses, the pause in PEPFAR support made it difficult, and in many cases impossible, to transport commodities to clinics.
• UNAIDS country offices have identified: the loss of thousands of HIV health workers in Kenya, Malawi, South Africa and Mozambique; disruptions to diagnostic and treatment services for pregnant women and children in Zimbabwe; partial or complete cessation of community outreach services in Angola and Eswatini; and the expected loss of a quarter of the workforce of the largest network of people living with HIV in Ukraine.
• A recent rapid assessment survey of 108 WHO country offices found that almost half reported moderate or severe disruptions to HIV services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• The roll-out of long-acting injectable PrEP, which PEPFAR had been slated to support, is now at risk.
• In addition to these impacts, modeling studies have estimated that:
• A 90-day PEPFAR funding pause and associated service disruptions could result in over 100,000 excess HIV-related deaths over a year in sub-Saharan Africa.
• Ending PEPFAR could result in up to 11 million additional new HIV infections and nearly 3 million additional AIDS-related deaths by 2030 across 26 countries. Another study found that ending funding in all 55 PEPFAR-funded countries could result in an additional 16 million deaths and 26 million new HIV infections by 2040.
• An additional 2-4 million deaths could occur each year in sub-Saharan Africa.
• In sub-Saharan Africa, ending PEPFAR funding could result in 565,000 new HIV infections over 10 years and reduced life expectancy of people living with HIV by 3.71 life-years.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), including for PEPFAR. It is unknown whether it will recommend limiting PEPFAR’s activities largely to care and treatment and/or whether other changes will be proposed, and how or if Congress will respond to these recommendations.
• Leadership. The President has not yet nominated a Global AIDS Coordinator and it is unclear when or whether someone will be nominated.
• Reauthorization: It is unknown if Congress will seek to reauthorize PEPFAR, which could afford it an opportunity to propose changes to the program and extend certain time-bound provisions.
• Reorganization. The proposed permanent dissolution of USAID and integration of any remaining USAID global health activities into GHSD, raises several questions, including whether additional capacities will be provided to allow for the management and implementation of PEPFAR as well as other health programs.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $1.9 billion reduction for PEPFAR. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of $400 million in FY 2025 funding for PEPFAR. Congress voted to amend the package, exempting PEPFAR from the rescission.

Introduction

Racial and ethnic disparities in health outcomes remain persistent in the United States, driven by inequitable access to and utilization of health care services and broader social and economic factors that reflect historical and ongoing racism. One factor that can mitigate these disparities is racial concordance between physicians and patients, that is, when providers and patients share the same racial or ethnic background. Research suggests that patient and provider racial concordance may be linked to increased visits for preventative care, greater treatment adherence, and lower emergency department use. One study found that greater representation of Black primary care physicians was associated with increased life expectancy and lower mortality among Black people. KFF 2023 survey data show Black, Hispanic, and Asian adults who have more health care visits with providers who share their racial and ethnic background more frequently report having positive and respectful interactions. Despite these benefits, many people of color face challenges accessing racially concordant providers. KFF survey data show that most Hispanic, Black, Asian, and American Indian and Alaska Native (AIAN) adults say that fewer than half of their health care visits in the past three years were with a provider who shared their racial or ethnic background. While data show that adults of color are more likely than White adults to prefer a provider of the same race or ethnicity, they are significantly less likely to have one and are more likely to have difficulty finding one.

Recent policy changes may exacerbate challenges to obtaining racially concordant care for those who value it most. In 2023, the U.S. Supreme Court effectively ended race-conscious admissions in higher education, overturning decades of precedent supporting affirmative action. Additionally, as one of his initial actions in office, President Trump issued executive orders eliminating federal diversity, equity, inclusion, and accessibility (DEIA) related programs and actions in the federal government and among federal contractors and grantees. These actions may reduce matriculation rates for students of color and reverse progress in diversifying the health care workforce to reflect the population it serves. For instance, research indicates that the Supreme Court’s 2023 ruling has already led to a decline in the number of Black, Hispanic, and AIAN students entering medical school. Among Black, Hispanic, AIAN, and Native Hawaiian and Pacific Islander (NHPI) medical school enrollees, there was a decline in matriculants between 2023 and 2024. Despite there being more Black and Hispanic applicants in 2024 compared to the previous year, the number of matriculants from historically underrepresented groups declined. It’s unclear how much impact the Supreme Court ruling has already had on medical school matriculation. However, the ruling has the potential to further decrease the diversity of the future physician workforce.

This brief provides an overview of the racial and ethnic composition of physicians compared to the total population at the national and state level based on KFF analysis of 2023 Association of American Medical Colleges (AAMC) Physician Workforce data and American Community Survey data. This analysis shows that Hispanic, Black, AIAN, and NHPI people were underrepresented among physicians relative to their share of the population, with the widest gap observed among Hispanic people who comprised 20% of the total population but only 7% of the total physician workforce. The pattern of underrepresentation held true across most states for Hispanic and Black people, with particularly large gaps for Hispanic people. Asian people accounted for a higher share of physicians than their share of the total population nationally and in all states; in most states, the share of White physicians was similar to or higher than their share of the total population. Data were not available for AIAN and NHPI populations in many states due to small numbers.

Racial and Ethnic Distribution of Physicians

Nationally, Hispanic, Black, AIAN, and NHPI people were underrepresented among physicians relative to their share of the population with the widest gap observed among Hispanic people. While one in five people in the U.S. population was Hispanic, they accounted for just 7% of the physician workforce (Figure 1). Similarly, 12% of the population was Black compared to 6% of the physician workforce. AIAN and NHPI individuals were also underrepresented among physicians compared to their share of the overall population. However, the absolute differences were small, as both groups make up less than one percent of the total population and the physician workforce. In contrast, White people accounted for similar shares of the total population and physician workforce, and Asian people accounted for a larger share of physicians (19%) than their share of the population (6%).

Across most states, Hispanic and Black people made up a smaller share of physicians compared to their share of the total population, with particularly large gaps for Hispanic people. In 45 states and DC, Hispanic people accounted for a smaller share of providers than their share of the population, as measured by a more than one percentage point difference (Figure 2). In seven states, the difference between the share of the population and providers who are Hispanic was over 15 percentage points. These tended to be states with the highest shares of Hispanic people, including New Mexico, California, and Texas. In New Mexico, Hispanic people made up nearly half (48%) the population but accounted for 17% of providers (a difference of 31 percentage points). In California and Texas, about 40% of the population was Hispanic compared to 7% and 13% of physicians, respectively. In only five states (West Virginia, Vermont, Maine, Mississippi, and Ohio) did Hispanic people account for a similar share of the population and the physician workforce, with a difference of less than one percentage point.

Similarly, in 35 of 50 states and DC, Black people made up a smaller share of physicians compared to their share of the population. In five states and DC, the difference between the share of the population and providers who are Black was 15 percentage points or higher, with the largest gap of 26 percentage points in DC and Mississippi (Figure 3). In DC, 17% of providers were Black compared with 43% of the population, and in Mississippi, Black people made up 11% of physicians compared with 37% of the population.

Data were insufficient for comparisons for AIAN and NHPI people in most states, but where data were available, AIAN and NHPI people were underrepresented among physicians relative to their share of the population. This pattern was most prominent in states where the majority of AIAN and NHPI people live. For example, In Alaska, AIAN people accounted for 14% of the population, seven times higher than their share of physicians (2%). Additionally, in New Mexico, AIAN people made up 9% of the population compared to 2% of providers, and in South Dakota they comprised 7% of the population compared with 1% of providers. Similarly, in Hawaii, NHPI people made up 10% of the population compared to 2% of physicians. In most remaining states, AIAN and NHPI people accounted for both a small share of the population and providers, so absolute differences in their shares were small.

Asian people accounted for a higher share of physicians than their share of the total population in all states. The largest differences were in Illinois, California, Delaware, and Texas. In Illinois, Asian people made up more than one in four physicians but accounted for only about 5% of the population (Figure 4). There were sizeable differences in the states with the highest shares of Asian people. In Hawaii, 37% of the population was Asian compared with 43% of providers, and in California, 15% of the population was Asian versus 32% of providers. The differences were smaller in other states, like Alaska, Montana, and Vermont, where Asian people accounted for a small share of both providers and the population.

In most states, the share of White physicians was similar to or higher than their share of the total population. States where White people were most underrepresented among physicians compared to their share of the population included West Virginia (67% vs. 90%), North Dakota (67% vs. 83%), and Michigan (58% vs. 73%) (Figure 5). The pattern in these states reflected higher representation of Asian people among physicians. States where White people were most overrepresented among physicians compared to their share of the population included New Mexico (56% vs. 37%), Alaska (77% vs. 58%), and Mississippi (70% vs. 55%).

A similar pattern was observed across medical specialties, with Hispanic and Black individuals underrepresented in more specialties than other racial and ethnic groups. Specialties providing primary care—such as family medicine, pediatrics, and obstetrics/gynecology—tended to better reflect the racial and ethnic distribution of the population. Among all specialties, providers in nephrology and interventional cardiology had the least racial and ethnic representation compared to the national population. The Hispanic population was the most underrepresented group in more than half of the specialties analyzed (27 out of 51 specialties). The Black population was the most underrepresented group in 9 out of 51 specialties.

San Francisco – KFF announced today that Dr. Victoria DeFrancesco Soto has joined KFF’s Board of Trustees. DeFrancesco Soto is the Dean of the Clinton School of Public Service at the University of Arkansas and previously served as Assistant Dean at the LBJ School of Public Affairs at the University of Texas at Austin. She has served as a trusted voice of political analysis for NBC News and Telemundo.

“It is my honor to serve on the KFF board,” said DeFrancesco Soto. “As an educator I am passionate about making research tangible to our day-to-day lives. KFF is a national model for translating the power of data and research into action. I am excited to roll up my sleeves and deeply engage in the impactful work of KFF.”

“Victoria’s deep knowledge of politics, policy, and media is a perfect fit for KFF, and we will benefit tremendously from her expertise and experience as we continue to expand our role as health care’s independent source of policy analysis, polling, and journalism,” said Dr. Drew Altman, President and CEO.

Dr. DeFrancesco Soto is the first Latina Dean at a presidential institution and is a fellow of the National Academy of Public Administration. She previously taught at Northwestern University and Rutgers and received her Ph.D. in political science from Duke University.

Her areas of expertise include civic engagement, women, immigration, Latinos and political psychology. Underlying all of her research interests is the applicability of high-quality, rigorous research to on-the-ground policy realities. 

KFF’s Board of Trustees is chaired by former U.S. Senator Olympia Snowe and its members have deep backgrounds in public service, academia, nonprofit organizations, health care, and the media.

Board members serve up to two, five-year terms. Additional information about KFF’s board can be found at https://www.kff.org/board-of-trustees/.

On July 14, 2025, the U.S. Department of Health and Human Services (HHS) issued a notice of a policy change to update the definition of “federal public benefits” as outlined in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) to add an additional 13 programs to the 31 programs considered “federal public benefits” that are restricted to individuals with a “qualified” immigration status. The notice further indicates that the updated list of federal benefits is not exhaustive, and additional programs may be added in the future. This change bars many groups of lawfully present immigrants as well as undocumented immigrants from accessing many health care, educational, and other social services and will likely have negative impacts on the health and well-being of immigrant families due to more limited access to services as well as confusion and fear about using services. It also may create new challenges and complexities for service providers. Many implementation questions remain unclear and subject to future guidance, including how verification of immigration status may occur and how the policy will be reconciled with existing conflicting statutory and regulatory requirements, which supersede the guidance. This policy change took effect immediately upon publication of the notice in the federal register on July 14, 2025, although it provides for a 30-day comment period. It also indicates that it will issue further implementation guidance.

Prior Policy under PRWORA

When enacted in 1996, PRWORA established federal requirements that limited eligibility for “federal public benefits” to groups who are “qualified immigrants.” The groups defined as “qualified immigrants” are more limited than groups who are considered lawfully present in the U.S. and exclude undocumented immigrants. Notably, qualified immigrants do not include people with Temporary Protected Status and people with deferred action, including Deferred Action for Childhood Arrivals recipients, among other lawfully present groups (Box 1).

The PROWRA legislation provided discretion to federal agencies to determine which benefits and programs are “federal public benefits,” while also identifying specific exemptions such as treatment for emergency medical conditions, certain disaster relief, immunizations, and testing and treatment for communicable diseases. It also clarified that non-profit organizations were not required to verify the immigration status of individuals receiving benefits or services. Under policy established in 1998, HHS identified 31 health and social programs considered to be “federal public benefits” restricted to “qualified immigrants,” including major health coverage programs such as Medicaid (excluding emergency Medicaid), Medicare, and the Children’s Health Insurance Program (CHIP).

Changes under the 2025 Policy

The 2025 policy expands the list of programs considered “federal public benefits” by adding 13 additional programs, including Head Start, the health center program, the Title X family planning program, among others (Box 2). The notice further indicates that the list is not exhaustive, and additional programs may be added to in the future.

Implications of the Policy Change

The policy change bars many lawfully present and undocumented immigrants from services that are important for their health and well-being. These programs include certain programs that are particularly important for immigrant families, such as the federal Health Center program, which funds a network of Community Health Centers (CHCs). Community health centers are a national network of over 1,300 safety-net primary care providers located in medically underserved communities and serve all patients regardless of their ability to pay, providing a range of medical, behavioral, and supportive services. Data from the 2023 KFF/LA Times Survey of Immigrants show that three in ten immigrant adults say a CHC is their usual source of care, with this share rising to about four in ten among likely undocumented immigrant adults (42%) and those with limited English proficiency (39%) (Figure 1). The policy also bars immigrants without a “qualified” immigration status from accessing federally funded mental and behavioral health services at a time when many immigrant families are experiencing heightened stress and anxiety due to immigration-related fears and financial uncertainty, as well as from Title X services, which provide comprehensive family planning services to low-income and uninsured individuals.

Beyond health care, the policy also limits access to services that support education, including the Head Start Program. Research shows that adults with higher educational attainment tend to have longer lifespans and be healthier than their counterparts with lower educational attainment. High educational attainment also is associated with better jobs that are more likely to provide employer-sponsored health coverage and higher incomes which, in turn, improve access to health care and resources to support health.

The new policy also will affect service providers who may need to update their policies and procedures to comply with the changes. Under PRWORA, program benefit providers are prohibited from providing “federal public benefits” to people who are not citizens or qualified immigrants and are required to verify that an applicant is a qualified immigrant eligible for services. The notice confirms an existing exemption in the law that non-profit charitable organizations are not required to verify immigration status. However, many implementation questions currently remain unclear and subject to future guidance, including how verification of immigration status may occur. Moreover, the policy does not supersede existing statutory and regulatory requirements. For example, although the notice limits the health center program to “qualified immigrants,” it does not change the underlying statutory requirements for CHCs to serve patients regardless of immigration status. While federal law supersedes guidance, this conflict creates challenges for CHCs in how they will apply this guidance, and it remains to be seen how enforcement of the guidance will affect CHCs’ ability to provide care. Additionally, as noted, the notice indicates that the list of programs affected by the change is not exhaustive, so additional programs may be added in the future.

The notice estimates that the policy change will result in savings from reduced use of programs by certain immigrants as well as new administrative costs. Savings are estimated to derive from excluding certain immigrants from HHS programs with a corresponding increase in benefits for U.S. citizens and qualified immigrants. There also are estimated to be new administrative costs associated with individuals being required to document their eligibility, for immigration status to be verified, and for changes in program eligibility and operating policies and procedures.

The policy change occurs against a backdrop of other policy changes restricting immigrant access to health and other programs and increased immigration enforcement activity. These changes include new restrictions established under budget reconciliation that limit Medicaid, Medicare, and subsidized Affordable Care Act (ACA) Marketplace coverage to lawful permanent residents, certain Cuban and Haitian entrants, and citizens of the Freely Associated States (COFA migrants). Together, these changes will likely have broad chilling effects on immigrant families, resulting in increased reluctance to access services and programs due to fear and confusion. More limited access to programs and services may lead to negative impacts on their health and well-being. These effects may extend across immigrant families, who often include citizen children—with one in four children in the U.S. living with at least one immigrant parent—and have broader impacts on communities, given immigrants’ role in the workforce.