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.

Note: For updated data on proposed ACA Marketplace premiums from more than 300 insurers in all 50 states and DC, read our updated analysis.

ACA Marketplace insurers are proposing a median premium increase of 15% for 2026, according to a new analysis of preliminary rate filings. Based on the early indications, individual market insurers will introduce the largest hike in premiums since 2018, the last time policy uncertainty contributed to sharp premium growth.

Across the 105 ACA Marketplace insurers in 19 states and DC that have submitted rate filings so far, most are requesting premium increases of 10% to 20% for 2026, and more than a quarter are proposing premium increases of 20% or more.

In addition to the anticipated growth in the cost of health care services, insurers have cited several policy changes that they expect to drive up rates next year, including the following:

• The expiration of the enhanced premium tax credits at the end of this year, which have made coverage more affordable and contributed to record-high enrollment in the ACA Marketplaces, is expected to drive up out-of-pocket premium payments by more than 75% on average and cause many healthier enrollees to drop their coverage.
• The impact of tariffs on some drugs, medical equipment, and supplies. Some insurers estimate that they could increase premiums by an average of 3% more than they otherwise would have.

Other factors could also affect premium changes, including the budget reconciliation legislation and Marketplace Integrity and Affordability rule, both of which were enacted and finalized after many of these insurers submitted their preliminary rate filings. Finalized 2026 rate changes are expected to be published in late summer.Subsidized enrollees are generally shielded from annual rate increases as their tax credits keep premium payments capped at a portion of their income.

However, with enhanced tax credits set to expire later this year if Congress takes no action to extend them, subsidized enrollees will pay more because they have less financial assistance. Middle income people with incomes above four times the poverty level would no longer be eligible for assistance and would have to shoulder the full premium.

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Note: For updated data on ACA Marketplace premiums from more than 300 insurers in all 50 states and DC, read our updated analysis.

This analysis of preliminary rate filings submitted by 105 ACA Marketplace insurers in 19 states and DC finds that ACA Marketplace insurers are requesting a median premium increase of 15% for 2026, which would represent the largest hike in premiums since 2018, the last time policy uncertainty contributed to sharp premium growth.

In addition to the anticipated growth in the cost of health care services, insurers have cited several policy changes that they expect to drive up rates next year, including the expiration of the enhanced premium tax credits at the end of this year and the impact of tariffs on some drugs, medical equipment, and supplies.

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Introduction

Extreme heat continues to be a pressing issue as 2024 was recognized as the hottest year ever experienced, and 2025 is slated to be one of the five warmest years on record, with experts predicting more extreme heat records over the next five years. Warm seasons have lengthened, become more frequent, and increased in intensity due to climate change. In early July 2025, communities in Texas, New Mexico, and North Carolina experienced deadly flash floods, with over 100 people dying in the Texas floods. Flash floods are primarily a summertime weather event, the combination of high humidity levels, drought, and heat create favorable conditions for torrential downpours and flash flood events. More flash floods are expected to occur in the U.S. during summer 2025 and research finds that the risk of future flash flood events will increase as the climate warms.

In recent years, there have been rising incidents of extreme heat, poor air quality, drought, and wildfire events both globally and across the country. Exposure to extreme heat poses major health risks that disproportionately affect those with limited resources. Research shows that between 1999 and 2023, the number of heat-related deaths in the U.S. increased by 117%, from 1,069 heat-related deaths in 1999 to 2,325 in 2023. Moreover, KFF analysis of data from the Centers for Disease Control and Prevention shows that American Indian or Alaska Native and Black people are at higher risk of experiencing a heat-related death compared to their White counterparts. Estimates suggest that heat events in the U.S result in approximately $1 billion in excess health care costs each year. If left unaddressed, climate change could cost the U.S. economy approximately $14.5 trillion over the next fifty years.

Prior administrations and state and local governments increased efforts to address climate change, extreme heat, and their impacts on human health in recent decades. However, more recent efforts by the Trump administration have reversed some of these prior actions. Rollbacks in federal actions to address climate change-related inequities broadly and the impacts of extreme heat specifically, may contribute to worse health outcomes, disproportionately impacting many populations that already face disparities in health, including lower income populations, people of color, and immigrants. The elimination of key offices, programs, and data tools makes it more difficult to assess and mitigate the health risks associated with environmental hazards, including extreme heat. Beyond the federal administrative actions already taken, cuts to federal funding may further erode efforts to reduce heat exposure and its health-related impacts. Some states have taken steps to mitigate exposure to extreme heat and its health impacts. However, without broader federal actions and standards, protections will vary across states. As climate change accelerates and intensifies extreme heat, the impacts of the rollbacks of environmental protections and equity initiatives will likely widen existing health disparities, reduce community resilience, and weaken the federal government’s ability to respond to extreme climate events.

This brief provides an overview of the federal and state landscape of recent policies addressing extreme heat and health equity.

Federal Efforts Related to Extreme Heat and Health

Prior administrations implemented efforts to address climate change, extreme heat, and their impacts on human health in recent decades. In 1990, President George H.W. Bush implemented the Global Change Research Act of 1990, which created the U.S. Global Change Research Program (USGCRP) and required the release of the National Climate Assessment (NCA) every four years. The USGCRP has advanced climate change research over the past 35 years, and the NCA continues to report scientific research on climate change and its impacts on the U.S., helping to inform community responses to climate-related challenges. The Clinton administration implemented an Executive Order on “Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations”, which required federal agencies to make identifying and addressing environmental justice a key part of their missions. Federal agencies were tasked with determining whether their programs had disproportionate detrimental effects on underserved populations through exposure to environmental hazards, including heat. The Executive Order also directed the creation of an Interagency Working Group on Environmental Justice to identify the disproportionate effects of environmental hazards exposure on communities of color and low income groups, and developing an environmental justice strategy. President George W. Bush’s administration was characterized by a withdrawal from leadership in federal regulation of climate change, including the U.S.’ withdrawal from the Kyoto protocol, an international agreement to lower greenhouse emissions that contribute to global warming and climate change. The Obama administration implemented the Memorandum of Understanding on Environmental Justice, highlighting the disproportionate burden of pollution and environmental hazards on communities of color and low income groups. The Obama administration also created the National Integrated Heat and Health Information System (NIHHIS), which sought to increase community preparedness for extreme heat events. NIHHIS integrated heat and health information across the federal government to support on-the-ground efforts to reduce the impacts of extreme heat on human health.

The Biden administration took additional steps to address the impacts of climate change, extreme heat, and exposure to environmental hazards on human health. These actions included the Executive Order, “Revitalizing Our Nation’s Commitment to Environmental Justice for All”, which created the Office of Environmental Justice and External Civil Rights to identify gaps in data and the cumulative impacts of environmental justice on underserved groups. The Biden administration also implemented Executive Order, “Tackling the Climate Crisis at Home and Abroad”, to elevate climate change as a national security priority. Among other actions, it established the Office of Climate Change and Health Equity (OCCHE) within the Department of Health and Human Services, which aimed to address the impact of climate change on health and developed tools to help track heat-related illnesses. Additionally, the U.S. Department of Housing and Urban Development implemented measures, including increasing utility allowances to help mitigate the effects of extreme heat in public housing.

The Biden administration also implemented policies to specifically address the impacts of extreme heat on workers. In 2022, the Occupational Safety and Health Administration (OSHA) launched the National Emphasis Program for Outdoor and Indoor Heat-Related Hazards, an enforcement program that sought to identify and eliminate or reduce worker exposures to occupational heat-related illnesses and injuries. The program was an expansion of the agency’s heat-related illness prevention initiative. In 2021, OSHA began engaging with stakeholders to develop regulations to protect workers from heat-related hazards and established a Heat Injury and Illness Prevention Work Group, which made recommendations for heat injury and illness prevention standards. In 2024, OSHA issued a proposed rule on Heat Injury and Illness Prevention in Outdoor and Indoor Work Settings. The proposed rule would require employers to have written heat injury and illness prevention plans, heat injury precautions, trainings, and evaluations. Specifically, it would require employers to provide workers with cool drinking water, shade, and more rest breaks once the heat index reached 90 degrees. The public comment period on the rule has closed, but OSHA conducted public hearings through July 2, 2025. Beyond the proposed rule, the administration launched its heat.gov website as a source of information on heat and health. Moreover in 2024, the U.S. Department of Health and Human Services released its National Heat Strategy, a plan to coordinate federal action to address extreme heat and its impacts.

On the first day of its second term, the Trump administration began implementing policies and regulations that reverse efforts to mitigate the impacts of extreme heat on health. President Trump signed Executive Order “Initial Recissions of Harmful Executive Orders and Action” and Executive Order “Ending Illegal Discrimination and Restoring Merit-Based Opportunity”, which revoked key climate change and environmental justice policies implemented by prior administrations. As part of efforts to eliminate diversity and disparities-related initiatives, the Trump administration eliminated environmental justice programs. These actions included eliminating the Low Income Home Energy Assistance Program, which helps low income Americans, many of whom are people of color, pay their energy bills and stay cool during the summer, and terminating grants from the U.S. Department of Agriculture’s urban forestry program, which sought to increase tree canopy cover in low income communities around the country, addressing tree inequity and exposure to extreme heat. The Department of Health and Human Services also eliminated OCCHE, which had developed tools to track heat-related illnesses. The Trump administration also cut more than 90% of the National Institute for Occupational Safety and Health, including the entire heat team involved in efforts to address heat-related illnesses and deaths among workers in the farming and construction industries. In April, the Centers for Disease Control and Prevention (CDC) also fired staff from its Division of Environmental Health and Science Practice (DEHSP) who sought to protect communities from exposure to heat waves, wildfires, and other environmental hazards as well as provided grants to local and state officials to create heat wave plans and build community cooling centers. However, as of June 11^th, 2025, at least 150 staff from the National Center for Environmental Health and nearly all workers from the DEHSP were reinstated.

The Trump administration has also taken actions that block or weaken state level climate measures, including heat protection rules. On April 8^th, President Trump issued Executive Order “Protecting American Energy from State Overreach,” which directs the Attorney General to identify and block state and local laws that address climate change, environmental, social, and governance initiatives, and environmental justice. CDC’s Climate and Health Program’s Climate-Ready States and Cities Initiative, which helped state and local health departments prepare for and respond to climate-related health outcomes was among the programs cut from CDC’s DEHSP. Thirteen jurisdictions (AR, CA, CT, FL, ME, NY, NC, OR, PR, San Francisco, VT, WI, County of Santa Clara) were recipients of grants from the program. North Carolina’s Department of Health and Human Services reports that the state’s Heat Health Alert System and Heat-Related Illness Surveillance System may be at risk due to these cuts. The alert systems help monitor and identify unhealthy heat levels and heat-related illnesses.

State Actions Related to Extreme Heat and Health

In recent years, many states have enacted climate change legislation related to extreme heat and its impact on human health. Some states, including Maryland, Massachusetts, New York, Vermont, and California, have introduced Climate Superfund Bills that seek to hold fossil fuel producers and refiners responsible for their impacts on climate change, strengthen infrastructure, increase community environmental resilience, and mitigate the impacts of climate change. For example, New York’s Climate Superfund Bill, the “Polluter Pays Bill” is expected to collect $75 billion over 25 years to fund infrastructure and other projects, including the building of cooling centers to help residents stay cool during heat waves. Additionally, some states, including New Jersey, New York, North Carolina, and Arizona, have released Extreme Heat Action Plans that seek to build community resilience through coordinated government action, educating the public on extreme heat, and developing heat-ready infrastructure. The plans also direct and coordinate investments in historically disadvantaged communities that are disproportionately vulnerable to extreme heat. In North Carolina, the Heat Action Toolkit includes steps for health care providers and other leaders to care for disproportionately affected communities during heat waves. Some states are also engaging in programs to mitigate the impact of extreme heat on Medicaid enrollees. As of July 2024, 13 states have used Section 1115 Medicaid waivers to facilitate access to air conditioning. Oregon was the first state to implement this program to support vulnerable residents during extreme heat events.

California, Colorado, Maryland, Minnesota, Nevada, Washington, and Oregon are addressing the health impacts of extreme heat on workers through comprehensive heat protection standards (Figure 1). These standards aim to protect workers who are at greater risk of heat-related illnesses. For example, California’s Heat Illness Prevention Standard mandates access to shade, cool water, and training for outdoor workers. Washington’s Outdoor Heat Exposure Rules implement specific temperature thresholds that trigger safety measures for workers. Thirteen additional states are in the process of developing their own occupational heat safety standards, including New Mexico, which has a Heat Illness and Injury Prevention Rule under public comment.

In contrast, Texas and Florida implemented legislation that limit their county- and municipal-level governments’ abilities to provide certain heat protections for outdoor workers. In 2023, Texas enacted House Bill 2127, also known as the “Death Star Bill,” which preempts local laws, including heat protection standards for outdoor workers. In 2024, Florida enacted House Bill 433, which prevents city and county governments from requiring that employers, including government contractors, provide heat protections for outdoor workers outside of those required under state or federal law. These protections include requiring water breaks and other cooling measures for outdoor workers.

On July 4, 2025, President Trump signed the recent reconciliation bill into law which is expected to leave millions of low- and moderate-income people uninsured as they lose access to Medicaid. Additionally, questions remain about whether Congress will preserve enhanced Affordable Care Act (ACA) premium tax credits for those with marketplace coverage, without which millions more could find premiums unaffordable, disenroll, and become uninsured. Given LGBT adults have lower incomes and higher rates of Medicaid coverage than non-LGBT adults, these changes could disproportionately impact this community. Additionally, as LGBT people experience a wide range of health disparities, cost barriers may serve to exacerbate these differences.

This brief reviews new data from the May 2025 KFF Health Tracking Poll on LGBT adult’s experiences and concerns related to health care affordability. Overall, the survey findings show that LGBT adults face more widespread problems and concerns with health care affordability compared to non-LGBT adults. While this may reflect the lower average incomes of LGBT adults, many of these concerns cut across income, with similar shares of LGBT adults reporting concerns regardless of whether they have lower- or more moderate- income.

Findings

U.S. adults face challenges affording a range of common expenses, including those related to health care. Half (51%) of LGBT adults say that in the past year, they or a family member living with them has had problems paying for food, housing, transportation, or other necessities. This compares to three in ten non-LGBT adults. Over one-third (36%) of LGBT adults say they or a family member living with them has had problems paying for health care, compared to one in five (21%) non-LGBT adults. The differences between these groups may be due in part to LGBT adults generally being younger and having lower household incomes than non-LGBT adults. However, even when looking only at those under 35 years old, LGBT adults are still more likely than non-LGBT adults to say they or a household member had problems paying for necessities (62% vs. 38%) and health care (46% vs. 24%).

LGBT adults with household incomes under $40,000 are more likely than LGBT adults with higher incomes to say they or a household member have experienced problems paying for food, housing and other basic necessities in the past year (63% vs. 36%). Issues with health care affordability cut across income levels among LGBT adults, as 40% of lower-income LGBT adults report problems paying for health care in the past 12 months, statistically similar to the share of higher-income LGBT adults who say the same (32%).

Paying for health care can be a burden for individuals and families, including for LGBT adults who tend to have lower incomes. About half (52%) of LGBT adults say it is difficult for them to afford their health care costs, including about one in five (18%) who say it is very difficult. This experience is more common among LGBT adults than non-LGBT adults and is driven by those finding affordability very difficult.

These challenges with affordability can have an impact on access to and willingness to seek care. Half (51%) of LGBT adults report that they have skipped or postponed getting the health care they needed in the past year because of the cost compared to one-third (34%) of non-LGBT adults. About half of LGBT adults with incomes under $40,000 (50%) and about half of those with incomes of $40,000 or more (53%) say they have skipped getting needed health care because of the cost. Additionally, one in four (25%) LGBT adults say their health got worse because they skipped or postponed care because of the cost, compared to 18% of non-LGBT adults who say the same.

Similarly, costs related to prescription drugs also lead some LGBT adults to take actions to reduce their expenses in this area. About one-third (32%) have taken an over-the-counter drug instead of getting a prescription filled, a quarter (26%) have not filled a prescription because of the cost, and almost as many (23%) have cut pills in half or skipped doses. More than four in ten LGBT adults (44%) report taking at least one of these actions, compared to about a third (32%) of non-LGBT adults. Notably, similar shares of LGBT adults with incomes under $40,000 and those with incomes of $40,000 or more report taking at least one of these cost saving actions with their prescription medications (43% and 46% respectively).

Not surprisingly, these experiences translate to worry. Over half of LGBT adults express worry about being able to afford each of the following for themselves and their family: health costs, unexpected medical bills, rent/mortgage, food, gas/transportation, and utilities. Worry about affording health costs and unexpected medical bills are among the expenses of greatest concern to LGBT adults, with about two-thirds reporting they are worried about these expenses (68% and 66%, respectively). LGBT adults are more likely than non-LGBT adults to report affordability concerns related to rent/mortgage, food, and gas/transportation and similarly likely to report such concerns related to health care costs.