Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024

Published: Jan 28, 2026
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Introduction

Virtually all enrollees in Medicare Advantage (99%) are required to obtain prior authorization for some services – most commonly, higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy. This contrasts with traditional Medicare, where only a limited set of services, including certain outpatient hospital services, non-emergency ambulance transport, and durable medical equipment, require prior authorization (see Box 1). Insurers often use prior authorization requirements to assess whether health care services are medically necessary before they are covered and to reduce unnecessary costs. At the same time, prior authorization processes and requirements, including the use of artificial intelligence to review requests, may result in administrative hassles for providers, delays for patients in receiving necessary care, and in some instances, denials of medically necessary services, such as post-acute care.

Prior authorization practices have gotten a fair amount of attention in recent years. KFF polling shows that most people view delays and denials of care by health insurance companies as a problem, with about two-thirds of Medicare beneficiaries reporting that they consider it to be a major problem. Last summer, the Trump Administration announced that private health insurers, including those that comprise a majority of Medicare Advantage enrollment, agreed to a voluntary initiative to improve the prior authorization process. Lawmakers in Congress have also been active on the issue, with bipartisan legislation introduced in both the House and Senate. Additionally, on January 1, 2026, the Administration launched the Wasteful and Inappropriate Spending Reduction (WISeR) model to test the use of enhanced technology to conduct prior authorization for an additional set of select services in traditional Medicare in six states.

This analysis uses data submitted by Medicare Advantage insurers to the Centers for Medicare and Medicaid Services (CMS) to examine the trends in the number of prior authorization requests, denials, and appeals for 2019 through 2024, as well as differences across Medicare Advantage insurers with the largest enrollment. It does not include requests or denials by type of service or type of plan because CMS does not collect or report this information, though such data could help inform consumers in choosing among plans. It also presents data from CMS about the use of prior authorization in traditional Medicare, including the number of requests and denials for fiscal years 2021 through 2024.

Key Takeaways

  • Nearly 53 million prior authorization requests were submitted to Medicare Advantage insurers on behalf of Medicare Advantage enrollees in 2024, an increase from 2023 (49.8 million) as the number of people enrolled in Medicare Advantage has grown. Substantially fewer prior authorization requests for traditional Medicare than Medicare Advantage beneficiaries were submitted to CMS – just over 625,000 in fiscal year 2024. 
  • In 2024, there were 1.7 prior authorization requests on average per Medicare Advantage enrollee, a slight decline from 1.8 in 2023. In contrast, in 2024, about 2 prior authorization requests were submitted per 100 traditional Medicare beneficiaries – a rate of about 0.02 per enrollee – which reflects the limited set of services subject to prior authorization in traditional Medicare.
  • In 2024, Medicare Advantage insurers fully or partially denied 4.1 million prior authorization requests, which is a somewhat larger share (7.7%) of all requests than in 2023 (6.4%) and similar to 2022 (7.4%). Though there were substantially fewer prior authorization requests for traditional Medicare beneficiaries, a larger share was denied – 22.9% (less than 150,000) in 2024.
  • A small share of denied prior authorization requests was appealed in Medicare Advantage –11.5% in 2024, similar to 2023 (11.7%).That represents an increase since 2019, when 7.5% of denied prior authorization requests in Medicare Advantage were appealed. The traditional Medicare data do not include information on appeals for 2023 and 2024, but in 2022 a relatively small share of denied prior authorization requests was appealed in traditional Medicare (6.4% in 2022).
  • Though a small share of prior authorization denials were appealed to Medicare Advantage insurers, most appeals (80.7%) were partially or fully overturned in 2024. Across all years examined, more than eight in ten appeals overturned the initial denial. These requests represent medical care that was ordered by a health care provider and ultimately deemed necessary but was potentially delayed because of the additional step of appealing the initial prior authorization decision. Such delays may have negative effects on a patient’s health.

Use of Prior Authorization in Medicare Advantage

CMS requires Medicare Advantage insurers to submit data for each Medicare Advantage contract (which usually includes multiple plans) as part of its oversight of Medicare Advantage plans. Insurers are required to submit the number of prior authorization determinations made during a year and whether the request was approved. Insurers are additionally required to report the number of initial decisions that were appealed (reconsiderations) and the outcome of that process, including whether the initial decision was affirmed, partially overturned, or fully overturned. These data are useful for assessing overall trends and variations across insurers, but do not contain the information necessary to understand how the use of prior authorization varies by type of service or type of plan because they are aggregated to the contract level. CMS is implementing a pilot program to collect more detailed data at the plan and service level this year, which would help assess whether some enrollees bear a higher burden of prior authorization requirements or are more frequently denied requested services. CMS states that it anticipates expanding the requirement to all plans in 2027.

In 2024, nearly 53 million prior authorization requests were submitted to Medicare Advantage insurers.

After dropping in 2020 amid the initial phase of the COVID-19 pandemic, prior authorization requests increased steadily between 2021 and 2024 (Figure 1). The decline in 2020 was likely due to both a decline in utilization, as well as the option for insurers to temporarily pause prior authorization requirements during the public health emergency.

Medicare Advantage Insurers Made Nearly 54 Million Prior Authorization Determinations in 2024

The increase in the total number of prior authorization requests since 2020 corresponds to an increase in Medicare Advantage enrollment. Between 2019 and 2024, the number of Medicare Advantage enrollees rose from 22 million people to 33 million people. Therefore, the number of prior authorization requests per enrollee has remained relatively constant in the past few years. In 2019, there were approximately 1.7 prior authorization requests per Medicare Advantage enrollee. That number dropped at the onset of the COVID-19 pandemic to 1.4 in 2020 and 1.5 in 2021, before returning to the pre-pandemic level of 1.7 requests per enrollee in 2022 and rising slightly to 1.8 in 2023. In 2024, Medicare Advantage enrollment growth outpaced the increase in the number of prior authorization requests, leading to a slight drop in the number of requests per enrollee to 1.7 (Figure 2).

The modest decline in the number of prior authorization determinations per enrollee corresponds with increased regulatory attention to prior authorization in Medicare Advantage which clarified the criteria that may be used by Medicare Advantage plans to establish prior authorization policies. In addition, certain Medicare Advantage insurers also announced changes to prior authorization practices in 2023 and 2024, such as UnitedHealth Group’s decision to reduce the number of services subject to prior authorization and launch a national “gold card” program that exempts certain providers from prior authorization requirements.

Prior Authorization Determinations per Medicare Advantage Enrollee Declined Slightly Between 2023 and 2024

Medicare Advantage insurers denied 4.1 million (7.7%) prior authorization requests in 2024.

Of the 52.8 million prior authorization determinations in 2024, more than 90% (48.7 million) were fully favorable, meaning the requested item or service was approved in full. However, the remaining 4.1 million prior authorization requests (7.7%) were denied in full or in part by Medicare Advantage insurers. This is slightly higher than the 6.4% of requests that were denied in 2023 and similar to the share denied in 2022 (Figure 3). Across all years, most denials (73% in 2024, data not shown) were denied in full, while a minority of denials were determined to be partially favorable, meaning that only part of the request was approved. For example, the insurer may have approved 10 of 14 requested therapy sessions.

Medicare Advantage Insurers Denied Fewer than 10% of Prior Authorization Requests in Recent Years

Just 11.5% of denied prior authorization requests were appealed to Medicare Advantage insurers in 2024.

As in previous years, the majority of the 4.1 million denied prior authorization requests were not appealed. Though the share of denied requests that are appealed is small at just 11.5%, similar to the share in 2023 (11.7%), it has risen over time, from 7.5% in 2019 (Figure 4). These include appeals of claims that were both fully and partially denied.

The Share of Denied Prior Authorization Requests Appealed to Medicare Advantage Insurers in 2024 Was Similar to 2023

The vast majority of denied prior authorization requests that were appealed were subsequently overturned by Medicare Advantage insurers.

In each year from 2019 through 2024, more than eight in ten denied prior authorization requests that were appealed were overturned (Figure 5). This raises questions about whether the initial request should have been approved, although it could also indicate that the initial request was missing the required documentation to justify the service. In either case, patients potentially faced delays in obtaining services that were ultimately approved because of the prior authorization process.

More Than 80% of Denied Prior Authorization Requests That Were Appealed Were Overturned

Variation in Use of Prior Authorization Across Medicare Advantage Insurers in 2024

In 2024, the volume of prior authorization determinations varied across Medicare Advantage insurers, as did the share of requests that were denied, the share of denials that were appealed, and the share of decisions that were overturned upon appeal, meaning people may have different experiences depending on the Medicare Advantage plan in which they enroll.

Across most insurers, fewer prior authorization requests per enrollee were correlated with a higher share of requests being denied and vice versa. For example, prior authorization requests for UnitedHealth Group Inc. and Humana Inc., the two largest Medicare Advantage insurers, were among the lowest (UnitedHealth Group Inc., 1.0 requests per enrollee) and the highest (Humana Inc., 2.2 requests per enrollee) observed, and correspondingly, denial rates were above average (UnitedHealthcare, 12.8%) and below average (Humana, 5.8%) for these insurers. 

While all Medicare Advantage insurers require prior authorization for at least some services, there is variation across insurers and plans in the specific services that are subject to these requirements. In addition, some insurers waive prior authorization requirements for certain providers, for example, as part of risk-based contracts or through “gold carding” programs that exempt providers with a history of complying with the insurer’s prior authorization policies.

Prior authorization requests were most common among Elevance and Centene plans.

The number of prior authorization requests per enrollee ranged from a low of 0.6 requests per enrollee in plans sponsored by Kaiser Foundation Health Plan, Inc. to a high of 3.0 requests per enrollee in Elevance Health, Inc. and Centene Corporation plans (Figure 6). Kaiser is atypical among insurers in that it generally operates its own hospitals and contracts with an affiliated medical group. Looking across other insurers that are more similar, the low end of the range was 1.0 prior authorization requests per enrollee in UnitedHealth Group, Inc. plans. Differences across Medicare Advantage insurers in the number of prior authorization requests per enrollee likely reflect some combination of differences in the services subject to prior authorization requirements, the frequency with which contracted providers are exempted from those requirements (which may be related to the extent to which providers are affiliated with the insurer), how onerous the prior authorization process is for a particular insurer relative to others, and differences in enrollees’ health conditions and the health care services they use.

Prior Authorization Determinations Are More Common Among Certain Medicare Advantage Firms

UnitedHealth Group denied the highest share of prior authorization requests while Elevance denied the fewest.

The denial rate ranged from 4.2% of prior authorization requests for Elevance Health plans to 12.8% of prior authorization requests for UnitedHealth Group plans (Figure 7). The overall denial rate includes requests that were both fully and partially denied (adverse and partially favorable determinations, respectively).

Most insurers that had more prior authorization requests per enrollee than average denied a smaller share of those requests than average, such as Elevance Health, which had 3.0 prior authorization requests per enrollee and a denial rate of 4.2%. Conversely, insurers with fewer prior authorization requests per enrollee denied a higher share of those requests, such as UnitedHealth Group, which had 1.0 prior authorization requests per enrollee and a denial rate of 12.8%. Centene Corporation was an exception with both a relatively high number of prior authorization requests (2.9 per enrollee) and a relatively high denial rate (12.3%).

Firms Denied Between 4.2% and 12.8% of Prior Authorization Requests

Across all insurers, a small share of denials was appealed.

Most denied prior authorization requests are not appealed to the Medicare Advantage insurer. The shares ranged from 1.6% for Kaiser Foundation Health Plan to 19.9% for CVS Health Corporation, with the appeal of fewer than one in twelve denials across all insurers except CVS Health Corporation (Figure 8).

Across Most Firms, Fewer than One in Eight Denied Prior Authorization Requests Were Appealed

Across all firms, more than half of appeals were successful.

Even though most denials were not appealed, when they were, most of the initial decisions were partially or fully overturned. The share of appeals that resulted in favorable decisions overturning the initial denial was lowest for Kaiser Foundation Health Plan (51.0%) and highest for Centene Corporation (95.5%) (Figure 9), which also had the second highest share of requests initially denied.

Across all Firms, More than Half of Prior Authorization Request Denials that Were Appealed Were Overturned

The Use of Prior Authorization in Traditional Medicare

The use of prior authorization is relatively new to traditional Medicare and only used for a limited set of services, including certain outpatient hospital services, non-emergency ambulance transport, and durable medical equipment (see Box 1). The prior authorization process does not change any documentation requirements that are necessary for receiving Medicare payment – the confirmation that coverage requirements are met are required earlier in the review process. CMS has published reports presenting data on the use of prior authorization in traditional Medicare for fiscal years 2021, 2022, 2023, and 2024. These reports include information on the number of requests received, reviews completed, and the number and share of requests that were affirmed. For 2021 and 2022 only, the data also include information on appeals and the outcome of the appeal.

Just over 625,000 prior authorization reviews were completed by CMS for traditional Medicare in 2024.

Across the three categories of services that required prior authorization, there were 216,571 reviews completed in 2021, 260,986 reviews completed in 2022, 393,749 reviews completed in 2023, and 628,243 reviews completed in 2024 (Figure 10). This translates to about 2 prior authorization reviews per 100 traditional Medicare beneficiaries in 2024.

CMS Completed Just Over 625,000 Prior Authorization Reviews for Traditional Medicare in 2024

Less than one-quarter of prior authorization requests in traditional Medicare were denied.

CMS approved (or affirmed) the majority of prior authorization requests it reviewed. CMS reported that 24.8% of requests were denied (or non-affirmed) in 2021, 27.6% of requests were denied in 2022, 28.8% of requests were denied in 2023, and 22.9% of requests were denied in 2024 (Figure 11). This reflects 53,680 denied requests in 2021, 72,029 denied requests in 2022, 113,448 denied requests in 2023, and 143,705 denied requests in 2024.

CMS Denied Less Than One-Quarter of Prior Authorization Requests for Traditional Medicare in 2024

In traditional Medicare, a small share of denied prior authorization requests was appealed to CMS and the share of prior authorization requests that were appealed and overturned upon appeal varied across service type.

In 2022, fewer than 5,000 denied prior authorization requests in traditional Medicare were appealed to the first level. As a share of all denied requests that translates to 6.4% appealed in 2022. Of the denied requests, 1,323 prior authorization denials were overturned upon appeal, which represents 28.7% of all first level appeals (Figure 12). Appeals data in traditional Medicare are presented differently across the CMS reports. Specifically, the 2023 and 2024 reports include a separate claims and appeals section for each category of service, which appears to include a broader universe of reviews by Medicare Administrative Contractors, including those for payment of services rendered, than what is presented in the report for 2021 and 2022. Given the differences in the data reported, we present appeals and whether the decision was overturned on appeal for 2022 only.

Prior Authorization Reviews, Denials, Appeals, and Outcome of Appeals in Traditional Medicare, by Category in FY2022

Denied requests for the ambulance transport services were most often appealed (19.6%); just 6.6% of denials for certain hospital outpatient services and 1.5% of certain durable medical equipment, prosthetics, orthotics and supplies requests were appealed.

The share of appeals that resulted in overturning the initial decision also varied widely. Nearly two-thirds (63.9%) of appeals for durable medical equipment, prosthetics, orthotics and other supplies were successful. That compares to 26.3% of appeals for the ambulance transport services and 22.2% of appeals for certain hospital outpatient services.

Box 1: Prior Authorization Requirements in Traditional Medicare

In 2015, CMS issued a final rule that established a prior authorization process for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items, with the goal of reducing the use of items that had been frequently subject to unnecessary utilization. Initial implementation began March 20, 2017, and items have been added and subtracted to the list over the following years through subsequent rulemaking. As of January 13, 2026, the DMEPOS items prior authorizations list includes over 70 items, including for pressure reducing support surfaces, power mobility devices, and lower limb prosthetics. Additionally, in December 2025, CMS issued a rule which establishes a prior authorization exemption process for certain DMEPOS items, allowing qualifying suppliers, such as those who show an affirmation rate of 90% or higher, to be exempt from prior authorization.

In a 2019 final rule (effective July 1, 2020), CMS established national prior authorization requirements for a set of hospital outpatient department services which had experienced significant increases in utilization and that are likely to be cosmetic procedures and not covered by Medicare, but may be combined with other therapeutic services, including blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation. In further rulemaking (effective July 1, 2021), CMS added implanted spinal neurostimulators and cervical fusion with disc removal to the list of services requiring prior authorization, and another rule (effective July 1, 2023) added facet joint interventions.

The CMS Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model uses the authority provided through the Center for Medicare and Medicaid Innovation (CMMI, or Innovation Center) to test whether prior authorization for non-emergent ambulances for certain medical appointments would save money for Medicare while maintaining access and quality of care. The model was first implemented in select states in December 2014 and was ultimately expanded nationwide in September 2020 as it met the model requirements, saving Medicare about $650 million over four years.

On January 1, 2026, the Center for Medicare and Medicaid Innovations (CMMI) launched the Wasteful and Inappropriate Service Reduction (WISeR) Model that establishes new prior authorization requirements in traditional Medicare for select services in six states (New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington). These services include skin substitutes (synthetic products used in the treatment of severe or chronic wounds), orthopedic pain management services, electrical nerve stimulator implants, incontinence control devices, and services related to the diagnosis and treatment of impotence. According to CMS, the model will test the use of enhanced technologies, such as artificial intelligence, to conduct prior authorization for services vulnerable to fraud or abuse.

Box 2: Recent Administrative Actions and Proposed Legislation on Prior Authorization

The Administration recently finalized three rules related to prior authorization.

The first rule (effective date: June 5, 2023) issued by the Biden Administration clarifies the criteria that may be used by Medicare Advantage plans in establishing prior authorization policies and the duration for which a prior authorization is valid. Specifically, the rule states that prior authorization may only be used to confirm a diagnosis and/or ensure that the requested service is medically necessary and that private insurers must follow the same criteria used by traditional Medicare. That is, Medicare Advantage prior authorization requirements cannot result in coverage that is more restrictive than traditional Medicare. The rule also describes how private insurers may consider additional information when traditional Medicare does not have fully established coverage criteria. The rules apply to coverage beginning with plan year 2024.

The second rule (effective date: April 8, 2024) issued by the Biden Administration is intended to improve the use of electronic prior authorization processes, as well as the timeliness and transparency of decisions, and applies to Medicare Advantage and certain other insurers. Specifically, it shortens the standard time frame for insurers to respond to prior authorization requests from 14 to 7 calendar days starting in January 2026 and standardizes the electronic exchange of information by specifying the prior authorization information that must be included in application programming interfaces starting in January 2027. It also requires that beginning in 2026, insurers post all items and services subject to prior authorization and the share of prior authorization requests that were approved, denied, and approved after appeal. A bipartisan bill has also been introduced to codify pieces of this rule.

The third rule (effective date: June 3, 2024) also issued by the Biden Administration would have required Medicare Advantage plans to evaluate the effect of prior authorization policies on people with certain social risk factors (“health equity analysis”) starting with plan year 2025, but the Trump Administration announced in June 2025 that it would not enforce these requirements.

Additionally, lawmakers in Congress have introduced several bills aimed improving the prior authorization process, including codifying changes made through recent rulemaking, and requiring written clinical criteria for prior authorization requirements, which were both introduced on a bipartisan basis. Other legislation would penalize insurers when initially denied requests are overturned upon appeal too often, require plans to include prior authorization information in plan advertisements, and one proposal would prohibit the use of prior authorization altogether.

Methods

The analysis of Medicare Advantage uses organization determinations and reconsiderations – Part C data from the Centers for Medicare and Medicaid Services (CMS) Part C and D reporting requirements public use file for contract years 2019 – 2021 and the limited data set for contract years 2022 through 2024. Medicare Advantage insurers submit the required data at the contract level to CMS and CMS performs a data validation check.

Data for Medicare Advantage contracts is aggregated to the parent company level. Insurers with less than 1 million enrollees into “other insurers”.

This analysis reflects data on service determinations and does not include claims determinations (for payment for services already provided). We also do not include withdrawn or dismissed determination requests in this analysis.

The enrollment data are from the CMS Medicare Advantage enrollment file for March of each year at the contract-plan-county level. We then sum up to the contract level to merge with the determination and reconsideration data. Contract-plan-county combinations are not included if there are fewer than 11 enrollees. The traditional Medicare analysis uses data included “Prior Authorization and Pre-Claim Review Program Stats,” published by CMS on September 15, 2023, which reflects prior authorization reviews completed in fiscal years 2021 and 2022, “Prior Authorization and Pre-Claim Review Program Stats for Fiscal Year 2023,” published on January 17, 2025, and “Prior Authorization and Pre-Claim Review Program Stats for Fiscal Year 2024,” published on September 16, 2025. The total number of traditional Medicare beneficiaries is from the Medicare Monthly Enrollment Dashboard for 2021 through 2024. While CMS published data on the use of prior authorization in traditional Medicare for FY2023 and FY2024, the information for appeals are not comparable to FY2021 and FY2022 data and are therefore not included in this analysis.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

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Published: Jan 27, 2026

Note: Originally published on Jan. 28, 2025, this resource is updated as needed, most recently on October 24, 2025, to reflect additional developments. 

Starting on the first day of his second term, President Trump began to issue numerous executive actions, several of which directly address or affect U.S. global health efforts.* This guide provides an overview of these actions, in the order in which they were issued. The “date issued” is date the action was first taken; subsequent actions are listed under “What Happens/Implications.” See an accompanying timeline of events specific to the foreign aid review and USAID dissolution.

President Trump’s Executive Actions on Global Health

Initial Rescissions Of Harmful Executive Orders And Actions, January 20, 2025
PURPOSE: Initial rescissions of Executive Orders and Actions issued by President Biden.

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What Happens Next/Implications: Given that most of the provisions in the COVID-19 and Global Health Security actions issued by President Biden are no longer current or relevant, the rescissions of these actions are likely to have minimal effect on government policies. One exception may be the elimination of the Directorate of Global Health Security and Biodefense and its Senior Director at the National Security Council, which were responsible for interagency coordination on global health security matters during the Biden Administration. The elimination of this office echoes a similar move made during the first Trump Administration to eliminate an NSC Directorate for Global Health Security, and raises questions about who and which offices at NSC (and across the government) will fill this coordination role in the new Administration. More rescissions of other Biden administration Executive Actions may be issued at a later date.
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As the largest donor to WHO providing approximately 16%-18% of the organization’s revenue, the absence of U.S. funding will have an impact WHO’s operations, as will the loss of U.S. technical expertise. See: KFF Fact Sheet and Quick Take

Update: The formal withdrawal of the U.S. government from the WHO became effective on January 22, 2026.
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• On February 10, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of two U.S. organizations seeking emergency relief from the freeze on funding for foreign assistance (AVAC v. United States Department of State).
• On February 11, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of several U.S. organizations challenging the executive order and subsequent actions freezing foreign aid and dissolving USAID, and asking the court to temporarily restrain and preliminarily and permanently enjoin Defendants from implementing these actions (Global Health Council v. Trump).
• On February 13, the court, in a ruling pertaining to the February 10 and February 11 lawsuits brought by numerous U.S. organizations, issued a TRO preventing the Trump administration from “suspending, pausing, or otherwise preventing the obligation or disbursement of appropriated foreign-assistance funds in connection with any contracts, grants, cooperative agreements, loans, or other federal foreign assistance award that was in existence as of January 19, 2025; or issuing, implementing, enforcing”, or “otherwise giving effect to terminations, suspensions, or stop-work orders in connection with any contracts, grants, cooperative agreements, loans, or other federal foreign assistance award that was in existence as of January 19, 2025.”
• On February 14, the parties filed a joint status report proposing an expedited preliminary injunction briefing schedule.
• On February 18, the government filed a required status report stating that, despite the TRO, it had the authority to cancel contracts and suspend grant awards.
• This was followed by a February 19 request by the February 10 plaintiffs (AVAC v. Department of State) for an emergency motion to enforce the TRO and to hold the defendants in civil contempt.
• The defendants filed a required response on February 20, stating that they have not violated the TRO and should not be held in contempt, which was again opposed by the plaintiffs. Also on February 20, the February 11 plaintiffs (Global Health Council v. Trump) filed a response to the defendant’s status report with a motion to enforce the TRO.  The court reaffirmed the TRO on February 20 (but did not hold the defendants in contempt), stating it was prepared to hold a hearing on the preliminary injunction motions in both cases by March 4, 2025 and that the TRO would be in place through March 10, 2025, or the date the Court resolves the preliminary injunction motions, whichever is sooner.
• The plaintiffs filed an emergency order to enforce the TRO on February 24, due to continued lack of payment, and the court issued a motion to enforce on February 25. The government appealed, (asking for a stay pending appeal) but this was denied by the court. The government then appealed to the Supreme Court and was granted a stay until February 28 while the case was considered.
• On March 5, the Supreme Court denied the government’s request to vacate the federal district court’s TRO, sending the order back to the district court to clarify the government’s obligations for ensuring compliance with the TRO.
• On March 6, the federal district court judge ordered the government to release all payments that were due to plaintiffs as of February 13, by Monday, March 10 at 6pm, and on March 10, the federal district court judge preliminarily enjoined the government from taking certain actions related to the foreign aid freeze.
• On March 10, Secretary Rubio announced that a six-week review had been completed and that 83% of programs at USAID (5,200 contracts) had been cancelled. That same day, the court  preliminarily enjoined the government from enforcing actions taken to implement the foreign aid freeze (requiring it to reverse any terminations, suspensions, and stop-work orders and to pay for any work completed by February 13). The court stated that the government was “enjoined from unlawfully impounding congressionally appropriated foreign aid funds and shall make available for obligation the full amount of funds that Congress appropriated for foreign assistance programs in the Further Consolidated Appropriations Act of 2024.”
• On April 1, the government filed an appeal with the U.S. Court of Appeals for the District of Columbia challenging the preliminary injunction issued on March 10.
• On April 17, the administration extended the foreign aid review for another 30 days from the original deadline of April 20, 2025.
•On May 2 and May 30, the White House released information on its budget request for FY 2026, proposing significant decreases, and in some cases eliminations, of funding for global health activities. However, Congress will determine the final funding levels.
• On June 3, the administration asked Congress to rescind previously appropriated funds for fiscal years 2024 and 2025, including $8.3 billion in foreign assistance, of which at least $1.2 billion was designated for global health. However, Congress will need to approve any potential rescissions.
• On August 13, the U.S. District Court of Appeals for the District of Columbia Circuit partially vacated the March 10 preliminary injunction in the cases GHC v. Trump and AVAC v. State Department which required the government to make congressionally appropriated foreign assistance funds available for obligation. The appeals court ruled that the plaintiffs did not have the authority to challenge the President’s impoundment of funds. Instead, the court ruled that challenges of impoundment should be brought forward by the Comptroller General.
• On August 28, the U.S. District Court of Appeals for the District of Columbia Circuit amended its opinion, clarifying that while plaintiffs did not have the authority to challenge impoundment of foreign assistance funds through the Impoundment Control Act, they could seek relief through the Administrative Procedures Act. Following this amended opinion, plaintiffs in GHC v. Trump and AVAC v. State Department cases motioned for a preliminary injunction in the U.S. district court on September 1. On September 3, the U.S. district court granted the preliminary injunction, ordering defendants to obligate expiring foreign assistance funds before the end of the fiscal year on September 30. On September 4, defendants appealed this preliminary injunction and requested a stay on the preliminary injunction pending the resolution of the appeals case, from both the district court and appeals court. These requests were both denied on September 5. On September 8, defendants requested a stay of the preliminary injunction as it pertained to funds included in the President’s proposed rescissions package from the U.S Supreme Court. On September 9, the Chief Justice of the Supreme Court granted a partial administrative stay of the preliminary injunction, and on September 26, the court granted the partial stay.

The 90-day review of foreign assistance was initially supposed to go through April 19, 2025, however, has been granted a 30-day extension.
America First Policy Directive To The Secretary Of State, January 20, 2025
PURPOSE: To put core American interests first in foreign policy.

The foreign policy of the United States “shall champion core American interests and always put America and American citizens first.”

“As soon as practicable, the Secretary of State shall issue guidance bringing the Department of State’s policies, programs, personnel, and operations in line with an America First foreign policy, which puts America and its interests first.”		What Happens Next/Implications: The State Department is responsible for the supervision and overall strategic direction of foreign assistance programs administered by the State Department and USAID, which includes the vast majority of global health assistance. It also directly oversees PEPFAR, the global HIV/AIDS program, and many aspects of global health diplomacy for the U.S. Priorities and approaches for these and other global health programs are likely to be shaped by how the White House and State Department leadership define “America First” foreign policy and American interests, and how that definition is implemented in practice.

In the President’s Budget Request for FY 2026, the request proposes eliminated funding for several global health activities, including family planning and reproductive health (FPRH), neglected tropical diseases (NTDs), and nutrition, stating these are “programs that do not make Americans safer”. However, Congress will determine final funding levels and whether to include these eliminations in its appropriations bills.

On September 18, the State Department released the America First Global Health Strategy, its new vision for U.S. global health engagement. The strategy is built around three pillars — “making America safer, stronger, and more prosperous” — and prioritizes funding for direct service support, such as commodities and health workers, includes plans for country co-investment, and seeks to transition program management operations from U.S. leadership to country ownership. The State Department states that it aims to enter into multi-year bilateral agreements with those recipient countries who receive most U.S. foreign assistance by December 31, 2025 and to implement these new agreements by April 2026. 
Defending Women From Gender Ideology Extremism And Restoring Biological Truth To The Federal Government, January 20, 2025
PURPOSE: To define sex as an immutable binary biological classification and remove recognition of the concept of gender identity.

• The order states that “It is the policy of the United States to recognize two sexes, male and female” and directs the Executive Branch to “enforce all sex-protective laws to promote this reality”. Elements of the order that may affect global health programs are as follows:
• Defines sex as “an individual’s immutable biological classification as either male or female”.  States that “sex” is not a synonym for and does not include the concept of “gender identity” and that gender identity “does not provide a meaningful basis for identification and cannot be recognized as a replacement for sex.”
• Directs the Secretary of Health and Human Services to provide the U.S. Government, external partners, and the public clear guidance expanding on the sex-based definitions set forth in the order within 30 days.
• Directs each agency and all Federal employees to “enforce laws governing sex-based rights, protections, opportunities, and accommodations to protect men and women as biologically distinct sexes, including when interpreting or applying statutes, regulations, or guidance and in all other official agency business, documents, and communications.
• Directs each agency and all Federal employees, when administering or enforcing sex-based distinctions, to use the term “sex” and not “gender” in all applicable Federal policies and documents.
• Directs agencies to remove all statements, policies, regulations, forms, communications, or other internal and external messages “that promote or otherwise inculcate gender ideology”, and shall cease issuing such statements, policies, regulations, forms, communications or other messages. Directs agencies to take all necessary steps, as permitted by law, to end the Federal funding of gender ideology.
• Requires that Federal funds shall not be used to promote gender ideology and directs agencies to ensure grant funds do not promote gender ideology.
• Rescinds multiple executive orders issued by President Biden, including: “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (13988) and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (14075).		What Happens Next/Implications: This order is broad, directed to all federal agencies and programs. Because PEPFAR, and some other U.S. global health programs, serve people who are members of the LGBTQ community, guidance and implementation could affect the ability of these programs to reach individuals and organizations and provide them with services. In addition, the order will likely result in the removal of existing protections based on sexual orientation and gender identity, which had been provided in agency guidance for global health and development programs. Implementation guidance has been issued and all federal agencies must comply.
Memorandum For The Secretary Of State, The Secretary Of Defense, The Secretary Of Health And Human Services, The Administrator Of The United States Agency For International Development, January 24, 2025
PURPOSE: To reinstate Mexico City Policy and direct review of programs per the Kemp-Kasten Amendment.

• Revokes President Biden’s Presidential Memorandum of January 28, 2021 for the Secretary of State, the Secretary of Defense, the Secretary of Health and Human Services, and the Administrator of the United States Agency for International Development (Protecting Women’s Health at Home and Abroad).
• Reinstates President Trump’s Presidential Memorandum of January 23, 2017 for the Secretary of State, the Secretary of Health and Human Services, and the Administrator of the United States Agency for International Development (The Mexico City Policy).
• Directs the Secretary of State, in coordination with the Secretary of Health and Human Services, to the extent allowable by law, to implement a plan to extend the requirements of the reinstated Memorandum to global health assistance furnished by all departments or agencies.
• Directs the Secretary of State to take all necessary actions, to the extent permitted by law, to ensure that U.S. taxpayer dollars do not fund organizations or programs that support or participate in the management of a program of coercive abortion or involuntary sterilization.		What Happens Next/Implications: The Mexico City Policy is a U.S. government policy that – when in effect – has required foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. funds) as a condition of receiving U.S. global family planning assistance and, when in place under the Trump administration, most other U.S. global health assistance. First announced in 1984 by the Reagan administration, the policy has been rescinded and reinstated by subsequent administrations along party lines since; it was widely expected that the President Trump would reinstate it in his second term. The new memorandum calls for the implementation of a plan to extend the requirements to global health assistance furnished by all departments or agencies; until the plan is ready, the scope of the new memorandum is unknown.

The new memorandum also directs the Secretary of State to review programs under the Kemp-Kasten amendment, a provision of U.S. law that states that no U.S. funds may be made available to “any organization or program which, as determined by the [p]resident of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.” It has been used in the past to prevent funding from going to UNFPA.

See: KFF Mexico City Policy explainer and related resources and Kemp-Kasten explainer.

Update: Three interim final rules expanding and implementing the Mexico City Policy, now called the Promoting Human Flourishing in Foreign Assistance (PHFFA) Policy, were issued on January 27, 2026:
– Protecting Life in Foreign Assistance
– Combating Gender Ideology in Foreign Assistance
– Combating Discriminatory Equity Ideology in Foreign Assistance Rules

Renewed Membership in the Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family, January 24, 2025
PURPOSE: To rejoin the Geneva Consensus Declaration.

The United States informed signatories of the Geneva Consensus Declaration of its intent to rejoin immediately. Established in 2020, the declaration, led by the United States, has the following objectives: “to secure meaningful health and development gains for women; to protect life at all stages; to defend the family as the fundamental unit of society; and to work together across the UN system to realize these values.”

What Happens Next/Implications: The Geneva Consensus Declaration, initially crafted and signed by the U.S. – along with 31 other countries at the time – was meant to enshrine certain values and principles related to women’s health and family, including a rejection of the “international right to abortion.”  The Biden administration withdrew from the Consensus in 2021.
Review of and Changes to USAID, January 27, 2025
Reorganization of the Department of State, April 22, 2025
PURPOSE: To review and potentially reorganize USAID “to maximize efficiency and align operations with the national interest,” which may include the suspension or elimination of programs, projects, or activities; closing or suspending missions or posts; closing, reorganizing, downsizing, or renaming establishments, organizations, bureaus, centers, or offices; reducing the size of the workforce at such entities; and contracting out or privatizing functions or activities performed by federal employees.What Happens Next/Implications: Related to but separate from the Executive Order on reevaluating and realigning foreign aid and on the America first policy directive to the Secretary of State, the administration has made changes to and begun a review of USAID, the U.S. government’s international development agency which oversees and/or implements most U.S. global health programs (see, The U.S. Government and Global Health). Key developments are as follows:
• On January 27, senior USAID career staff were placed on leave and hundreds of other staff were let go.
• On February 2, the USAID website was taken down.
• On February 3, the USAID building in DC was closed, which has prevented other staff from accessing it.
• The President appointed Secretary of State Rubio as Acting USAID Administrator on February 3. Secretary Rubio has said that the agency has “conflicting, overlapping, and duplicative functions that it shares with the Department of State” and that its systems and processes are not “well synthesized, integrated, or coordinated, and often result in discord in the foreign policy and foreign relations of the United States.” President Trump and other administration officials have called for dissolving the agency altogether. Formal notification of the intent to review the agency was sent by Secretary Rubio to Congress on February 3.
• On February 4, a notice was posted on the USAID website stating that on February 7, all USAID direct hire personnel would be placed on administrative leave globally, with the exception of “designated personnel responsible for mission­ critical functions, core leadership and specially designated programs.” The notice also said that staff posted outside the United States would need to return to the U.S. within 30 days.
• On February 6, a lawsuit was filed by Democracy Forward and Public Citizen Litigation Group, on behalf of the American Foreign Service Association and American Federation of Government Employees, challenging the foreign aid funding freeze, the plan to put most staff on leave, and the fact that staff had already been placed on leave; on February 7, they filed for a temporary restraining order (TRO). That same day, a temporary restraining order was issued by the U.S. District Court in the District of Columbia preventing the government from placing additional staff on leave or evacuating staff back to the U.S., and requiring reinstatement of all staff already placed on leave, until February 14. The court did not grant a TRO on the funding freeze, on the grounds that the plaintiffs in this case did not demonstrate that the freeze caused them irreparable harm. On February 13, the court extended the TRO through February 21, at which time, the court determined that further preliminary injunctive relief was not warranted and the TRO was ended, allowing the government to dismiss USAID staff.
• On February 11, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of several U.S. organizations challenging the executive order pausing foreign aid, and subsequent actions freezing foreign aid and dissolving USAID, and asking the court to temporarily restrain and preliminarily and permanently enjoin Defendants from implementing these actions. In a February 13 ruling, a federal court issued a TRO preventing the Trump administration from freezing foreign aid assistance but stated that the proposed injunctions related to USAID were overbroad (in a separate case, the district court ended the TRO on dismissing USAID staff – see above).
• On February 13, a lawsuit was filed in the U.S. District Court for the District of Maryland by 26 former and current employees of USAID, suing Elon Musk and DOGE for taking actions to control and dissolve the agency. On February 18, the plaintiffs filed a motion for preliminary injunction. The defendants responded on February 24 and the plaintiffs replied on February 26. On March 18, the court granted a preliminary injunction, requiring the defendants to reverse many of the actions taken to dissolve USAID, and on March 21, the defendants filed an appeal on the preliminary injunction. On March 25, the U.S. 4th Circuit Court of Appeals granted the defendants’ motion for a temporary stay on the preliminary injunction, allowing DOGE to resume its efforts to dissolve USAID, until March 27. The following day on March 28, the court granted defendants’ motion for a stay, clearing the path for DOGE to continue its work dissolving USAID.
• On February 18, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of the Personal Services Contractor Association (representing USAID personal service contractors) challenging the suspension of foreign assistance and the actions related to USAID, including “steps to dismantle USAID, cripple its operations, or transfer its functions to the State Department without Congressional authorization”. On February 19, the plaintiffs filed a motion for a temporary restraining order. On March 6, the court denied the TRO request.
• On March 28, Secretary Rubio announced that the Department of State and USAID have notified Congress on their intent to “undertake a reorganization that would involve realigning certain USAID functions to the Department by July 1, 2025, and discontinuing the remaining USAID functions that do not align with Administration priorities.” Additionally, nearly all the remaining USAID staff received notice that they would be subject to a final reduction-in-force.
• On April 22, Secretary Rubio announced the Department of State’s reorganization plan and new organization chart. The plan states that it would consolidate functions and remove non-statutory programs that are “misaligned with America’s core national interests.”
• On April 28, a lawsuit was filed by a group of labor unions, non-profits, and local governments challenging the administration’s moves to drastically reshape several federal agencies without congressional approval (American Federation of Government Employees v. Trump). The district court issued a TRO on May 9 and preliminary injunction on May 22 ordering the administration to pause large-scale reductions in force, program eliminations, and other actions related to federal agency restructuring. An emergency motion by the government for a stay pending appeal of the district court’s preliminary injunction was denied on May 30.
• On May 2 and May 30, the White House released information on its budget request for FY 2026, noting the reorganization of USAID into the Department of State.
• On May 29, the Department of State notified Congress of its reorganization plans, including absorbing USAID’s continued functions.
• On June 13, the district court in American Federation of Government Employees v. Trump ruled that the actions of the Department of State, including the reorganization announcement and notification to Congress, were in violation of the preliminary injunction.
• On July 8, the U.S. Supreme Court granted the government’s request for a stay of the preliminary injunction pending resolution of the appeals case in American Federation of Government Employees v. Trump, allowing the government to move forward with large-scale reductions to federal agency operations and workforces, including at the State Department.

While initially created through Executive Order in 1961 as part of the State Department, the Foreign Affairs Reform and Restructuring Act of 1998 established it as an independent agency within the executive branch. As such, the Executive branch does not have authority to dissolve it without Congress, and Congress also requires notification first as well as consultation on any proposed changes.

Update: On July 1, 2025, USAID was dissolved (with most employees being separated from the agency; any remaining personnel were separated by September 2, 2025). Remaining functions/activities were transferred to the State Department.
Withdrawing the United States From and Ending Funding to Certain United Nations Organizations and Reviewing United States Support to All International Organizations, February 4, 2025
PURPOSE: To review United States participation in all international intergovernmental organizations, conventions, and treaties and to withdraw from and end funding to certain United Nations (U.N.) organizations.

• The U.S. “helped found” the U.N. “after World War II to prevent future global conflicts and promote international peace and security.  But some of [its] agencies and bodies have drifted from this mission and instead act contrary to the interests of the United States while attacking our allies and propagating anti-Semitism.”
• States that the U.S. “will reevaluate our commitment to these institutions,” including three organizations that “deserve renewed scrutiny”:
a) the U.N. Human Rights Council (UNHRC; the U.S. will not participate in and withhold its contribution to the budget of the body),
b) the U.N. Educational, Scientific, and Cultural Organization (UNESCO; the U.S. will conduct a review of its membership in the body within 90 days), and
c) the U.N. Relief and Works Agency for Palestine Refugees in the Near East (UNRWA; reiterates that the U.S. will not contribute to the body).
• Requires that within 180 days:
a) the Secretary of State, with the U.S. Ambassador to the U.N., conduct a review of all international intergovernmental organizations of which the U.S. is a member and provides any type of funding or other support, and all conventions and treaties to which the United States is a party, to determine which organizations, conventions, and treaties are contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed; and
b) the Secretary of State to report the findings of the review to the President, through the National Security Advisor, and provide recommendations as to whether the U.S. should withdraw from any such organizations, conventions, or treaties.		What Happens Next/Implications: With a long history of multilateral global health engagement, the U.S. is often the largest or one of the largest donors to multilateral health efforts (i.e., multi-country, pooled support often directed through an international organization). It provided $2.4 billion in assessed or core contributions in FY 2024 – 19% of overall U.S. global health funding – as well as more funding in voluntary or non-core contributions.

The U.S. is also a signatory or party to numerous global health-related international conventions, treaties, and agreements; these include those that played a role in the global COVID-19 response (such as the International Health Regulations). It often has participated in negotiations for new international instruments, although the Trump administration indicated in a Jan. 20, 2025, Executive Order, listed above, that the U.S. would no longer engage in the Pandemic Agreement (sometimes called the “Pandemic Treaty”) negotiations.

This Executive Order will have immediate impacts via the ordered actions related to the three U.N. organizations specified, much as the impacts of the Jan. 20, 2025, Executive Order on the World Health Organization (WHO, which initiated U.S. withdrawal from membership and halted U.S. funding) are already being seen. Beyond these, additional impacts of this Executive Order will be determined by the findings and recommendations of the international organizations and conventions review, particularly if U.S. support for or membership in some international organizations is recommended to be reduced or eliminated and if it recommends the U.S. withdraw from any international agreements.

Congressional notification and oversight of any proposed changes will also be important to watch, including debates about whether advice or consent or congressional notification periods are or may be required prior to withdrawing the U.S. from international instruments such as treaties.

The administration has already signaled plans to discontinue support for several international organizations in its budget request for FY 2026 by proposing eliminated funding for Gavi, the Pan American Health Organization (PAHO), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Health Organization (WHO). However, Congress will determine final funding levels and whether to include these eliminations in its appropriations bills.

The 180 day review of all international intergovernmental organizations goes through August 3, 2025.
Memorandum For The Heads Of Executive Departments And Agencies, February 6, 2025
PURPOSE: The memorandum seeks to “stop funding Nongovernmental Organizations that undermine the national interest and administration priorities”.

The memorandum:

• States: it is Administration policy “to stop funding NGOs [Nongovernmental Organizations] that undermine the national interest.”
• Directs heads of executive departments and agencies to review all funding that agencies provide to NGOs and “to align future funding decisions with the interests of the United States and with the goals and priorities of my Administration, as expressed in executive action; as otherwise determined in the judgment of the heads of agencies; and on the basis of applicable authorizing statues, regulations, and terms.”		What Happens Next/Implications: This memo aligns with other Executive actions that target federal funding for global health and foreign assistance programs. Implementation of this memo could result in the Administration halting funding to global health NGOs they determine “do not align with administration priorities.” No criteria for how this determination will be made has been provided.

The majority of U.S. global health assistance is channeled through NGOs. In FY22, for example, 62% of U.S. global health funding was provided to NGOs as prime partners (45% to U.S.-based NGOs and 17% to foreign-based NGOs) and others are likely sub-recipients of U.S. assistance.* As such, this Order could have a significant impact on NGOs if it is determined that they do not align with administration policies.

*Source: KFF analysis of data from www.foreignassistance.gov.
Addressing Egregious Actions of The Republic of South Africa, February 7, 2025
PURPOSE: To stop U.S. support for South Africa due to its “commission of rights violations in its country or its ‘undermining United States foreign policy, which poses national security threats to our Nation, our allies, our African partners, and our interests.”

“It is the policy of the United States that, as long as South Africa continues these unjust and immoral practices that harm our Nation:
(a)  the United States shall not provide aid or assistance to South Africa; and
(b)  the United States shall promote the resettlement of Afrikaner refugees escaping government-sponsored race-based discrimination, including racially discriminatory property confiscation.”

ACTIONS:

• All executive departments and agencies, including USAID, shall, to the maximum extent allowed by law, halt foreign aid or assistance delivered or provided to South Africa, and shall promptly exercise all available authorities and discretion to halt such aid or assistance.
• The head of each agency may permit the provision of any such foreign aid or assistance that, in the discretion of the relevant agency head, is necessary or appropriate.
• The Secretary of State and the Secretary of Homeland Security shall take appropriate steps, consistent with law, to prioritize humanitarian relief, including admission and resettlement through the United States Refugee Admissions Program, for Afrikaners in South Africa. A plan shall be submitted to the President through the Assistant to the President and Homeland Security Advisor.		What Happens Next/Implications: South Africa receives a significant amount of global health assistance, particularly for HIV/AIDS, from the United States government. The executive order allows the heads of U.S. agencies to permit the provision of foreign aid or assistance under this order at their discretion. On February 10, the U.S. Embassy and Consulates in South Africa announced that PEPFAR would not be impacted by this Executive Order and could continue under the limited waiver already granted to the foreign aid funding freeze. No other exceptions have yet been announced.

The Government of South Africa has issued a statement in response to the Executive Order that, among other things, expresses concern “by what seems to be a campaign of misinformation and propaganda aimed at misrepresenting our great nation.”

Notes and Sources:

*There are several other Executive Actions issued by the President that instruct all government agencies on a variety of topics and as such broadly affect global health program operations but are not specific to global health. These include, for example, Executive Actions withdrawing from the Paris Agreement under the United Nations Framework Convention on Climate Change and ending DEI programs. These are not included in this resource.

Sources: White House, https://www.whitehouse.gov/presidential-actions/; State Department, www.state.gov.

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Medicaid and Upcoming State Budget Debates

Published: Jan 23, 2026

As states begin budget debates for state fiscal year (FY) 2027, many states are facing a more tenuous fiscal climate. Slowing revenue growth and heightened spending demands coupled with anticipated federal Medicaid cuts under the 2025 reconciliation law, changes to the Affordable Care Act (ACA) enhanced Marketplace subsidies, and economic changes are contributing to tighter budget conditions and fiscal uncertainty for states. Medicaid is often central to state fiscal decisions as it is simultaneously a significant spending item as well as the largest source of federal revenues for states.

States projected Medicaid enrollment to remain flat for FY 2026 in KFF’s 2025 budget survey of Medicaid officials and total Medicaid spending was expected to increase 7.9%, though there was substantial variation across states. States reported a variety of cost pressures including provider and managed care rate increases, greater enrollee health care needs, and increasing costs for long-term care, pharmacy benefits, and behavioral health services. Some states have already implemented Medicaid spending cuts to address recent budget challenges, and others may follow as they contend with budget gaps and prepare for the implementation of the Medicaid changes in the 2025 reconciliation law.

Now in January 2026, halfway through FY 2026, governors are beginning to release proposed budgets for state legislatures to consider for FY 2027. Most states will be adopting FY 2027 budgets this year and another 16 states enacted biennial budgets last year, though some of these states may adopt a supplemental budget for FY 2027. The state budget cycle in most states runs from July to June, and governors typically release their budget proposals early in the calendar year followed by a convening of the legislature to finalize and enact a budget. While most states have not yet released budget proposals, implementation of the 2025 reconciliation law will put pressure on state Medicaid programs and states such as Colorado and Idaho have already announced Medicaid cuts. Medicaid issues are also likely to intersect with broader health care coverage and affordability debates leading up to the mid-term elections in November 2026. There will be 39 gubernatorial elections (18 incumbent governors running for reelection and 21 incumbent governors who are either term-limited or not seeking reelection) and control of state legislative bodies could also be affected. This brief describes current state fiscal conditions as states begin FY 2027 budget debates and highlights key areas to watch for Medicaid policy changes as states respond to fiscal challenges and the 2025 reconciliation law. 

State Fiscal Pressures

States are facing a more tenuous fiscal climate as they prepare for FY 2027 budget debates. In recent years, tax cuts combined with changes in inflation and consumer consumption patterns has led to slowing state revenue growth following a period of record-breaking revenue and expenditure growth for states after the initial pandemic-induced economic downturn (Figure 1). General fund spending has also slowed, and data show state rainy day fund capacity is also beginning to decline following all-time highs (though funds remain stronger than before the pandemic). States are also contending with increasing spending demands from Medicaid, employee health care, education, housing, and disaster response, though state fiscal conditions vary widely across states. Due to tightening budget conditions, some states have begun implementing more budget management strategies, like spending cuts or other cost containment measures.

General Fund Revenues and Spending Have Slowed Following Pandemic-Era Highs

Recent federal actions, including the passage of the 2025 reconciliation law, may intensify state budget pressures for FY 2027. States are preparing for significant policy changes and federal funding cuts in the 2025 reconciliation law, including tax code changes as well as Medicaid and SNAP cuts. The new law is expected to reduce federal Medicaid spending by $911 billion (or 14%) over the next decade, though the impact varies by state. States may offset some of the reductions with state funds, though the challenging fiscal climate and the magnitude of federal funding cuts in the new law may make it difficult. For example, states may consider filling in funding gaps created by losses in federal funding for Planned Parenthood or providing state funded coverage for lawfully present immigrants who lose health coverage due to new eligibility restrictions. Some states are also moving to subsidize ACA Marketplace premiums with state funds following the expiration of the enhanced subsidies. The expiration of the enhanced subsidies as well as federal workforce cuts, tariff changes, and shifts in economic conditions contribute to heightened fiscal uncertainty for states. While not expected to offset rural hospitals’ losses under the reconciliation law and funding amounts will vary, states will be receiving additional federal funding through a new rural health fund. Given state budget challenges and fiscal uncertainty, at least 14 states, including Arizona, California, Colorado, Delaware, Maryland, New Mexico, and Rhode Island, have already forecasted budget gaps for FY 2027.

State Medicaid Changes

In response to mounting state budget pressures and the passage of the 2025 reconciliation law, FY 2027 state budget debates may include efforts to reduce Medicaid spending. Even though many provisions of the reconciliation law do not take effect immediately, a few states have already implemented Medicaid spending cuts for FY 2026 and, heading into the FY 2027 budget cycle, states may continue to propose Medicaid policy changes in key areas (Figure 2). This brief includes Medicaid changes from recently announced governors’ budget proposals, though most states have not yet released detailed budget proposals yet. The state budget landscape will likely continue to evolve as revenue forecasts and spending demands become clearer and as more states release their budgets. Given the timing and disparate impact of the reconciliation law across states as well as variation in state fiscal conditions, FY 2027 Medicaid policy changes will vary by state and some Medicaid cuts may not begin until FY 2028 or later.

Figure 2

Medicaid State Budgets: Key Policy Areas to Watch

Provider Rates

States have substantial flexibility to establish Medicaid provider reimbursement methodologies and amounts, especially within a fee-for-service (FFS) delivery system where a state Medicaid agency pays providers or groups of providers directly. Historically, during times of weak state revenue collections, states have typically turned to provider rate restrictions to contain costs. KFF’s 2025 Medicaid budget survey found that adopted FY 2026 budgets included more rate increases than cuts, but there was a notable uptick in states reporting provider rate restrictions compared to previous years. Some notable restrictions in FY 2026 included 4% across the board reductions for all provider types and services in Idaho, and a reversal of 1.6% across the board provider rate increases to address budget shortfalls in Colorado.

State budget pressures and the 2025 reconciliation law may result in additional rate cuts in FY 2027 budgets. While the 2025 reconciliation law did not directly make changes to how states set provider rates, the law imposes new limits on managed care state-directed payments for inpatient hospital and nursing facility services and new restrictions on states’ ability to generate Medicaid provider tax revenue. Some provider tax provisions in the new law have already been implemented, and some states may be anticipating the effect of future provider tax limits that will be phased on over time, which could exacerbate state budget challenges and result in reimbursement rate cuts. Some early FY 2027 governors’ budget proposals include provider rate restrictions: Colorado proposed reducing Medicaid provider rates to 85% of Medicare rates, along with rate reductions for certain home health, dental, behavioral health, and other services, and Idaho proposed extending their 4% provider rate reductions. Texas has also proposed reimbursement rate reductions for FY 2027 for substance use treatment facilities and durable medical equipment. North Carolina has not yet passed their biennial budget for FY 2026 and FY 2027; while this stalemate resulted in rate cuts that were eventually restored in FY 2026, the legislature may consider additional cuts as they finalize their budget.  

Benefits

State Medicaid programs must cover a comprehensive set of “mandatory” benefits, including items and services typically excluded from traditional insurance, but may also cover a broad range of optional benefits. For example, all states cover prescription drugs as an optional benefit, and most states cover other optional services such as physical therapy, eyeglasses, and adult dental care. KFF’s 2025 Medicaid budget survey found that benefit expansions continued to far outweighed benefit restrictions and limitations in FY 2026 (consistent with prior survey years), particularly for behavioral health. However, some states had plans to restrict coverage of GLP-1s for obesity treatment, including California, New Hampshire, Pennsylvania, and South Carolina, which all eliminated coverage of GLP-1s for obesity treatment in January 2026, likely reflecting recent state budget challenges and fiscal uncertainty.

As states enter FY 2027 budget debates, it may be challenging to sustain recent benefit expansions and states may face increased pressure to cut or limit optional benefits. While the 2025 reconciliation law does not directly change Medicaid benefits, states may have to cut or limit optional benefits to offset federal funding cuts in the new law or respond to existing budget challenges. Colorado’s recently released governor’s budget proposal for FY 2027 includes capping dental benefits, and Rhode Island’s Medicaid program FY 2027 budget proposal considers ending GLP-1 coverage. Idaho governor’s budget proposal includes suggested cuts to dental, pharmacy, and various medical service benefits.

Home Care             

Medicaid pays for almost 70% of all home care spending in the U.S., and most Medicaid home care is provided through optional services, giving states flexibility to manage costs. Most states use various mechanisms to limit home care spending under waiver programs, including caps on enrollment, total spending, and per-participant costs, as well as restrictions on specific services like personal care. Nearly a third of states reported planning to adopt new strategies in FY 2026 to contain home care costs, according to data from KFF’s 2025 survey of officials administering Medicaid home care programs.

State budget challenges and federal funding cuts in the 2025 reconciliation law could result in additional pressure to reduce optional home care services in FY 2027 budgets. The 2025 reconciliation law does not directly change home care benefits, but significant Medicaid spending on home care and the availability of mechanisms for limiting such spending could spur states to make home care cuts. When faced with fiscal pressures in the past, all states reduced spending on home care by either serving fewer people (40 states) and/or by cutting benefits or payment rates for long-term care providers (47 states). Recently released governors’ budget proposals from Colorado and Idaho include suggested cuts to home care services, although specifics of these proposals are not available and may evolve during the legislative process.

Eligibility and Work Requirements

Since the pandemic, many states have expanded Medicaid eligibility or taken steps to remove administrative barriers to enrollment for certain groups. States have also built on post-pandemic unwinding strategies to automate eligibility and renewal processes, improve communication with members, and reduce administrative barriers. However, in FY 2026, some states reduced Medicaid spending through eligibility restrictions, reflecting tighter budget conditions. As of January 2026, California reinstated asset limits for Medi-Cal eligibility for long-term care benefits for adults 65 and older or with a disability, and D.C. reduced Medicaid income limits to 138% of the federal poverty limit for certain enrollees. Some states have also rolled back state-funded health coverage programs that expand coverage to immigrants regardless of status. In addition, KFF’s 2025 Medicaid budget survey found that a few states planned to cancel or postpone one or more projects or initiatives due to uncertainty at the federal level, including federal waiver policy changes such as pre-release coverage for individuals who are incarcerated or continuous enrollment for children.

Upcoming FY 2027 budget debates may consider Medicaid eligibility restrictions to address state budget challenges. States will also begin the implementation of the 2025 reconciliation law’s Medicaid eligibility policy changes, including pausing implementation of some provisions in the Biden-era Eligibility and Enrollment Final Rule (that aimed to streamline complex processes), restricting Medicaid eligibility for certain immigrants, conducting more frequent eligibility redeterminations for ACA expansion adults, and imposing Medicaid work requirements for ACA expansion adults. Operationalizing these new policies will require significant changes to state eligibility systems and processes, which may displace staff, funding, and resources from implementing other Medicaid priorities. Increased costs associated with implementing the changes in addition to state budget pressures and federal funding cuts could mean more states consider restricting coverage of optional eligibility groups. For example, Idaho’s legislature has signaled that it may consider repealing the Medicaid expansion to address budget shortfalls.

The implementation of Medicaid work requirements may have a significant impact on state Medicaid program budgets and systems capacity in FY 2027. The 2025 reconciliation law requires states to implement work requirements for individuals enrolled through the ACA Medicaid expansion pathway or certain state waivers beginning January 1, 2027 (with the option for states to implement requirements earlier). The Congressional Budget Office (CBO) estimates that this requirement will have the largest effect on spending and coverage compared to other provisions, reducing federal Medicaid spending by $326 billion over ten years and resulting in 5.3 million more people who are uninsured. In KFF’s 2025 Medicaid budget survey, states reported a number of implementation challenges including the significant eligibility systems changes needed, the short timeframe, staff capacity concerns, and issues for applicants and enrollees. States also reported fiscal challenges tied to systems changes, hiring additional staff, and conducting outreach to enrollees. Even with implementation funds and federal matching payments for administrative costs, some states cited the increased costs of implementing work requirements on a short timeline as a concern, which may factor into FY 2027 budget debates. For example, among recently released FY 2027 governors’ proposed budgets, Utah includes $16.5 million, Colorado includes over $50 million, Kentucky includes $35.6 million, and Wyoming includes $7.4 million in funding for the new law’s Medicaid eligibility redetermination changes. In addition, some states are planning to move forward with work requirements before the federal deadline, which could have additional implications for state budgets. To date, Nebraska is the first state to announce it will implement early, starting May 1, 2026.

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Medicaid: What to Watch in 2026

Published: Jan 23, 2026

At the start of 2026, many issues are at play that could affect Medicaid coverage, financing, and access to care. Medicaid, which is administered by states within broad federal rules, provides comprehensive health and long-term care coverage to one in five low-income Americans. A more tenuous fiscal climate in 2026 coupled with implementation of the 2025 reconciliation law will put pressure on state Medicaid programs. While major legislative changes to Medicaid at the federal level are unlikely in 2026, key areas to watch include federal policy actions such as new regulations or guidance related to work requirements, implementation guidance for other components of the 2025 reconciliation law, and states’ policy actions in response to federal policy changes and state budget pressures.

Medicaid issues are likely to intersect with broader health care coverage and affordability debates, including the expiration of the enhanced premium tax credits for Affordable Care Act (ACA) coverage and efforts by the administration to control drug prices and hold insurance companies accountable, leading up to the mid-term elections in November 2026. At the federal level, these elections could affect the make-up of Congress and at the state level, they could affect control of state legislatures and governors’ offices. There will be 39 gubernatorial elections (18 incumbent governors running for reelection and 21 incumbent governors who are either term-limited or not seeking reelection).

Medicaid Coverage

In 2026, states will begin implementing Medicaid policy changes that are estimated to increase the number of people without health insurance by 7.5 million in 2034. Over half (5.3 million) of people newly uninsured from Medicaid changes would come from new work requirements for Medicaid enrollees in the ACA Medicaid expansion group or enrollees in partial expansion waiver programs (Georgia and Wisconsin) starting January 1, 2027. Beyond work requirements, the 2025 reconciliation law made other Medicaid eligibility changes, including pausing implementation of some provisions in two Biden-era eligibility and enrollment rules (that aimed to streamline complex processes), restricting Medicaid eligibility for certain lawfully-present immigrants, and requiring states to conduct more frequent eligibility redeterminations for ACA expansion adults.

States will need to make major policy decisions and systems upgrades, likely in advance of formal federal guidance, to be ready to implement work requirements in January 2027. Operationalizing new Medicaid work requirements will require changes to state eligibility systems and processes, enhanced data sharing infrastructure, and targeted enrollee outreach and education, all of which will demand staff resources and funding that will limit attention to other Medicaid priorities. The short timeline for making these changes means states will need to move forward with key decisions before formal guidance from the Centers for Medicare and Medicaid Services (CMS) may be available, increasing the risk that they will have to make adjustments to align with federal policy, which could increase costs. Despite these challenges, some states have indicated a desire to implement work requirements before the January 2027 deadline. To date, Nebraska is the first to announce it will begin enforcing federal work requirements early, starting May 1, 2026.

Federal immigration policies and state policy choices could have implications for Medicaid coverage in 2026. In addition to federal legislative changes, broader immigration policies, such as changes to the public charge rules, new agreements for CMS to share Medicaid data with Department of Homeland Security (DHS) and Immigration and Customs Enforcement (ICE), and continued public immigration enforcement activity could result in fewer legal immigrants obtaining or maintaining Medicaid coverage. In the face of increasing fiscal pressure, several states have announced they are rolling back state-funded coverage for immigrants who are not eligible for federally-funded Medicaid, which will further limit coverage options for immigrants. States may also adopt other eligibility restrictions in an effort to reduce state costs. 

Medicaid Financing

Cuts to federal Medicaid spending will exacerbate the fiscal challenges states are experiencing because of slowing revenue growth and increasing spending demands. The 2025 reconciliation law made historic cuts to federal Medicaid financing, which are estimated to reduce federal Medicaid spending by $911 billion over 10 years. Although the most significant changes to federal Medicaid financing don’t take effect until October 2027 or later, some states will experience more immediate effects resulting from changes to federal requirements governing provider taxes. One of the most immediate effects is that states are prohibited from establishing any new provider taxes or increasing existing taxes. Historically, states have used provider taxes as a means of sustaining Medicaid funding in times of slowing revenue growth or increasing spending demands, but that tool is no longer available because of the new prohibition.

Some states may also face reductions to states’ budgeted revenues for 2026 because of more immediate changes to federal provider tax rules. This would occur in two types of cases:

  • States that had adopted new provider taxes for state fiscal year (FY) 2026 may not be able to implement those taxes if they had not done so by July 4, 2025, and
  • States that have implemented provider taxes with a special waiver from CMS known as a “uniformity waiver,” may need to revise their taxes as early as April 1, 2026 because of new limits on the use of such waivers (estimated to affect at least seven states including California, Illinois, Massachusetts, Michigan, Ohio, New York, and West Virginia).

To address slowing revenue growth and increasing spending demands, states may seek to restrict Medicaid provider reimbursement rates, benefits, or eligibility to reduce state Medicaid spending. For example, four states eliminated GLP-1 coverage for obesity treatment in late 2025 likely reflecting recent state budget challenges and fiscal uncertainty. While state Medicaid programs must cover nearly all drugs, a long-standing statutory exception allows states to choose whether to cover weight-loss drugs under Medicaid, resulting in limited state coverage of GLP-1s for obesity treatment. Recent governors’ budgets have included restrictions for other Medicaid benefits including dental and home care. States’ fiscal challenges in 2026 stem from factors other than the 2025 reconciliation law, but the law may exacerbate such challenges. Beyond limiting revenues in states affected by the provider tax provisions, states will need to spend more to implement the law’s requirements, most notably the new work requirements that start January 1, 2027. While the 2025 reconciliation law included some resources to implement policy changes, states may need to make additional investments in systems or workforce to comply with multiple and complex policy changes. Because states pay less than 50% of total Medicaid costs, reductions in state funding will have even larger effects on total Medicaid spending. For example, on average, states accounted for 35% of total Medicaid spending in federal fiscal year 2024. At that rate, a decrease of $100 million in state Medicaid spending would decrease total Medicaid spending by $286 million.

Recent Trump administration prescription drug initiatives could result in savings for state Medicaid programs, though questions remain about the implementation and impact of the deals. In fall 2025, the Trump administration announced reaching agreements with some drug manufacturers, including Pfizer and AstraZeneca, to provide most-favored nation (MFN) prescription drug pricing in Medicaid. MFN prices will be available to state Medicaid programs through the GENEROUS (GENErating cost Reductions fOr U.S. Medicaid) Model, a voluntary drug payment model through which CMS will negotiate supplemental drug rebates based on prices paid in other countries. The Trump administration also recently announced the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model, another voluntary model that intends to expand access to obesity drugs in Medicaid and Medicare by negotiating lower GLP-1 prices with manufacturers. While lower prices for state Medicaid programs through the recently announced models could result in reduced Medicaid prescription drug spending and potentially expanded coverage of obesity drugs, how the new lower costs under the models compare to the net prices state Medicaid programs currently pay and how states or manufacturers will respond remain unclear. Due to the design of the Medicaid Drug Rebate Program (MDRP), Medicaid programs already typically pay lower prices, net of rebates, than other payers. Further, the recent announcements will not impact costs for Medicaid enrollees as they already pay little or no copays for prescription drugs.

Medicaid Access to Care

State decisions to restrict provider reimbursement rates or benefits in response to federal Medicaid spending cuts could limit access to care for some Medicaid enrollees in 2026. Changes to Medicaid financing will make it difficult for states to increase payment rates to providers and may create pressure for states to restrict payment rates. Reduced or stagnant payment rates to providers coupled with rising costs and increases in the number of people who are uninsured (from Medicaid and Marketplace coverage changes) could pressure providers to reduce staff, services or potentially close. Some providers already struggling financially, such as rural hospitals or hospitals serving a high share of Medicaid enrollees, could face more challenges. An influx of funding from the Rural Health Transformation Program may help to mitigate some challenges in the near term, but those funds are temporary and not expected offset the full magnitude of Medicaid funding cuts over the next ten years. Restricting Medicaid coverage of “optional” services (like behavioral health or home care) could result in less access to care for people with complex health conditions. This may be particularly likely for home care services, where existing tools for managing spending such as caps on total spending or enrollment make it easier for states to limit spending in the future.

The administration may shape Medicaid access through actions to curtail or approve new Section 1115 Medicaid demonstration waivers. Such waivers allow states an avenue to test new approaches in Medicaid if the Department of Health and Human Services (HHS) Secretary determines the waiver is likely to “promote the objectives of the Medicaid program.” Waiver priorities may shift from one presidential administration to another. For example, the Trump administration has rescinded Biden-era 1115 waiver guidance on covering health-related social needs (HRSN) services, indicated plans to phase out certain waiver financing tools (related to use of “Designated State Health Programs” (DSHP), notified states that it does not anticipate approving or extending waivers with continuous eligibility provisions for children and adults or workforce initiatives. While the Trump administration has indicated the phase out or rescission of certain Biden-era waiver policies, the administration has not provided details about its priorities for the use of 1115 waivers. The 2025 reconciliation law included a new provision that requires the Chief Actuary at CMS to certify that 1115 waivers are not expected to result in an increase in federal expenditures compared to federal expenditures without the waiver. While “budget-neutrality” for waivers has been required under long-standing policy and practice, typically the calculations are determined on a per enrollee basis over the course of the waiver and are negotiated between states and the administration.

Workforce challenges tied to reimbursement rate policies and changes in immigration policy could also exacerbate access challenges. KFF survey data finds that 13% of immigrants have avoided going to work since January 2025 because of concerns about drawing attention to someone’s immigration status, a number which rises to 40% among people who are likely to be undocumented immigrants. Such concerns are most significant for the long-term care workforce because Medicaid is the dominant payer for care and more than one in four long-term care workers are immigrants. Beyond long-term care, immigrants constitute a large share of workers in other health care fields, including over one in four physicians in US hospitals.

What to Watch

The issues identified in this policy watch could have major implications for Medicaid coverage, financing, and access to care. Key questions for each of these areas will be important to monitor as debates evolve leading up to the mid-term elections, which will have significant implications for Medicaid and health policy in general in the years ahead.

Medicaid coverage changes:

  • How will federal guidance shape implementation of work requirements and other eligibility changes in the reconciliation law?
  • How will states implement Medicaid work requirements? How many states will implement work requirements ahead of the January 2027 deadline? Will any states be granted good faith waivers to delay implementation?
  • Will states adopt additional eligibility restrictions in budgets for FY 2027?
  • How will aggregate and state enrollment trends evolve during 2026?

Medicaid financing changes:

  • How will federal Medicaid financing changes affect state budgets and provider rates in 2026?
  • How will state financing challenges affect the development of their FY 2027 budgets?
  • Will states be able to offset reduced federal funding with state funding or will states adopt policies to restrict Medicaid? What policies will states adopt to reduce state Medicaid spending?
  • Will states be able to sustain recent increases in provider rates or expansions in services, particularly for long-term care and behavioral health?

Medicaid access changes:

  • How will broader changes in Medicaid coverage affect access to care?
  • How will changes in Medicaid 1115 waiver policy affect access to care?
  • Will changes in financing result in hospital or other provider closures and what will that mean for access to care? Will funding for providers from the rural health transformation fund offset restrictions from other federal and state policies?
  • How will broader immigration policies affect the long-term care workforce and access to services that are predominantly funded by Medicaid?
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How Has U.S. Spending on Health Care Changed Over Time?

Published: Jan 22, 2026

This chart collection explores National Health Expenditure (NHE) data from the Centers for Medicare and Medicaid Services (CMS), including the latest data from 2024. These data offer insights into changes in health spending over time in the U.S., as well as the driving forces behind spending growth. A related interactive tool contains more of the latest NHE data.

The slideshow is part of the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

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State Recommendations for Routine Childhood Vaccines: Increasing Departure from Federal Guidelines

Authors: Jennifer Kates and Clea Bell
Published: Jan 22, 2026

In anticipation of federal changes to vaccine policy by the Trump administration, last year, some states began to de-couple their own vaccine recommendations from the federal government. This marked a departure from prior practice where, historically, states typically relied on Centers for Disease Control and Prevention (CDC) and its Advisory Committee on Immunization Practices (ACIP) for such recommendations.  Starting in May of last year, HHS Secretary Kennedy and the CDC/ACIP began to make changes to the federal vaccine schedule for children, culminating in an announcement on January 5 of this year with the most wide-ranging changes to date (see Table 1). Collectively, these changes have resulted in reducing the number of diseases targeted from 17 to 11 and the number of routine vaccines from 13 to 7. As part of these changes, six vaccines are no longer recommended for routine use by all children in the United States.

This policy brief tracks the number of states that have announced they are no longer following federal government recommendations for childhood vaccines as of January 20, 2026, updating an analysis from September of last year (while the current analysis focuses on state sources for childhood vaccine recommendations, our earlier analysis also looked at state actions regarding insurance coverage requirements and pharmacist administration).  Overall, the number of states that have taken such an action has increased significantly since last September, with a majority of states (28) now departing from federal guidelines for some or all childhood vaccines compared to 22 states in September of last year (see Table 2). Moreover, the number of states decoupling their vaccine recommendations for all childhood vaccines has risen from just nine in September to 25. The red-blue divide across the country continues to grow, with all blue states1 (those with Democratic governors) having announced that they will no longer follow federal guidelines, though four states with Republican governors have also done so.

Findings

As of January 20, 2026, the majority of states (28 states, including DC) have announced that they will not follow the new CDC childhood vaccine recommendations for at least some childhood vaccines, instead relying on prior recommendations, state recommendations, and/or those of external entities. Most of these states have indicated that they will follow the recommendations of the independent medical association, the American Academy of Pediatrics (AAP). Among these are two inter-state public health alliances which previously formed to develop shared recommendations and have reaffirmed their intent to follow AAP guidelines: the West Coast Health Alliance, which includes California, Hawaii, Oregon, and Washington, and the Northeast Public Health Collaborative, which includes ten states and New York City.

Almost all of these states (25 of 28) have announced that they will do so for all childhood vaccines. Most of these states are choosing to follow non-federal guidelines for all childhood vaccines. The three states that are more limited are Alaska and Mississippi, which announced that they would continue to recommend the Hepatitis B vaccine at birth for all infants, even those whose mothers test negative (no longer recommended as routine by the CDC), and Arizona, which has announced that it will continue to recommend Hepatitis B at birth and COVID-19 vaccines consistent with guidelines from external entities.

This marks a significant increase since September when only nine states had announced that they would not follow CDC/ACIP vaccine recommendations for all childhood vaccines (some also did so for adults). In September, most states that had announced changes did so for COVID-19 only (13), which at that time, was the only vaccine for which changes had been made by the federal government (removing the routine vaccination recommendation generally, including for children). With the changing recommendation regarding Hepatitis B vaccine in December of 2025 and additional vaccines in early January 2026, many more states have expanded this scope to include all childhood vaccines.

The red-blue divide in vaccine policy continues with all blue states (those with Democratic governors) departing from federal guidelines. As in September, there is a significant political divide in vaccine policies across the country, which is even sharper today. While all blue states have departed from federal recommendations (one exception is Virginia which just swore in a new Democratic Governor this week and may choose to change their position regarding vaccine recommendations soon), four states with Republican governors have also done so for at least some childhood vaccines (Alaska, Mississippi, New Hampshire, and Vermont). This divide in state policy mirrors a growing divide in public opinion).

Looking ahead, it is possible other states will join this group and de-couple their own childhood vaccine recommendations from the federal government. Regardless of future state decisions, the current landscape – with diverging recommendations from the federal government, many states, and physician organizations — represents a challenging one for parents and providers to navigate, which could dampen already falling vaccination rates.  Moreover, much of this divide is likely to play out in the next school season, when states have to decide whether and how to translate their vaccine recommendations into school attendance requirements or revise existing exemption allowances.  

Table 1: Trump Administration Changes to Childhood Vaccine Recommendations
Disease(s)/VaccineChange Date
COVID-19No  longer routine5/27/25; September 2025
Hepatitis B (HepB)No  longer routine12/16/25
Human papillomavirus (HPV)Reduced from 2 or 3 doses to 1 dose1/5/26
Rotavirus (RV)No  longer routine1/5/26
InfluenzaNo  longer routine1/5/26
Hepatitis A (HepA)No  longer routine1/5/26
Meningococcal ACWY (MenACWY)No  longer routine1/5/26
Note: In addition to these changes, the federal government is no longer recommending the combined MMRV product or the multi-dose influenza vaccine with Thimerosal.
Sources: https://www.hhs.gov/press-room/cdc-adopts-individual-based-decision-making-for-hepatitis-b-immunization-for-infants-born-to-women-who-test-negative-for-the-hepatitis-b-virus.html; https://www.hhs.gov/sites/default/files/decision-memo-adopting-revised-childhood-adolescent-immunization-schedule.pdf; https://x.com/seckennedy/status/1927368440811008138; https://www.hhs.gov/press-room/cdc-immunization-schedule-individual-decision-covid19-standalone-chickenpox-toddlers.html.
Table 2: State Childhood Vaccine Recommendations: Reliance on Non-Federal Sources
StateParty of
Governor		Relies on non-Federal Source for Routine
Childhood Vaccine Recommendations
 

 

As of September 22, 2025
All Vaccines: 9 States
COVID-19 only: 13 States		As of January 20, 2026
All Vaccines: 25 States
COVID-19/Hepatitis B: 1 State
Hepatitis B only: 2 States
AlabamaR  
AlaskaR Hepatitis B
ArizonaDCOVID-19 OnlyCOVID-19/Hepatitis B
ArkansasR  
CaliforniaDAll VaccinesAll Vaccines
ColoradoD All Vaccines
ConnecticutDCOVID-19 OnlyAll Vaccines
DelawareDCOVID-19 OnlyAll Vaccines
District of ColumbiaDAll VaccinesAll Vaccines
FloridaR  
GeorgiaR  
HawaiiDAll VaccinesAll Vaccines
IdahoR  
IllinoisDAll VaccinesAll Vaccines
IndianaR  
IowaR  
KansasD All Vaccines
KentuckyD All Vaccines
LouisianaR  
MaineDCOVID-19 OnlyAll Vaccines
MarylandDAll VaccinesAll Vaccines
MassachusettsDAll VaccinesAll Vaccines
MichiganDCOVID-19 OnlyAll Vaccines
MinnesotaDCOVID-19 OnlyAll Vaccines
MississippiR Hepatitis B
Missouri*R  
MontanaR  
NebraskaR  
Nevada*R  
New HampshireR All Vaccines
New JerseyDCOVID-19 OnlyAll Vaccines
New MexicoDCOVID-19 OnlyAll Vaccines
New YorkDCOVID-19 OnlyAll Vaccines
North CarolinaDCOVID-19 OnlyAll Vaccines
North DakotaR  
OhioR  
OklahomaR  
OregonDAll VaccinesAll Vaccines
PennsylvaniaDAll VaccinesAll Vaccines
Rhode IslandDCOVID-19 OnlyAll Vaccines
South CarolinaR  
South DakotaR  
TennesseeR  
TexasR  
UtahR  
VermontRCOVID-19 OnlyAll Vaccines
Virginia**D  
WashingtonDAll VaccinesAll Vaccines
West VirginiaR  
WisconsinDCOVID-19 OnlyAll Vaccines
WyomingR  
Notes: *While news reports for Missouri and Nevada indicate that these states do not anticipate making changes to their vaccine recommendations, despite CDC changes, these were not attributed to specific officials or other documentation and were therefore not included here.  **As of January 17, 2026, Virginia’s governor is now a Democrat, the state may choose to change its position regarding vaccine recommendations soon.

Sources:

Alaska: https://alaskapublic.org/news/health/2025-12-30/alaska-sticks-with-universal-hepatitis-b-vaccine-despite-federal-update; Bill introduced: https://www.akleg.gov/basis/Bill/Detail/34?Root=HB%20238

Arizona: https://directorsblog.health.azdhs.gov/newborns-receive-hepatitis-b-vaccine-at-birth-for-good-reason/

California: https://www.cdph.ca.gov/Programs/OPA/Pages/NR26-001.aspx

Colorado: https://cdphe.colorado.gov/press-release/colorado-reaffirms-evidence-based-vaccine-guidance-and-continued-access-for-families

Connecticut: https://www.health.ny.gov/press/releases/2026/2026-01-12_pediatrics_vaccine_schedule.htm

Delaware: https://www.health.ny.gov/press/releases/2026/2026-01-12_pediatrics_vaccine_schedule.htm

District of Columbia: https://dchealth.dc.gov/release/dc-health-responds-cdc%E2%80%99s-decision-reduce-childhood-vaccines

Hawaii: https://www.cdph.ca.gov/Programs/OPA/Pages/NR26-001.aspx

Illinois: https://x.com/IDPH/status/2008590092475252895?s=20

Kansas: https://www.kdhe.ks.gov/m/newsflash/home/detail/1839

Kentucky: https://kyperf.sharepoint.com/sites/KPhA/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FKPhA%2FShared%20Documents%2FMarketing%2FKPhA%20Website%20and%20Blog%2FKDPH%20Letters%2FKDPH%5FVaccine%20Recommendation%20Letter%5F1%2E7%2E25%2Epdf&parent=%2Fsites%2FKPhA%2FShared%20Documents%2FMarketing%2FKPhA%20Website%20and%20Blog%2FKDPH%20Letters&p=true&ga=1

Maine: https://www.maine.gov/dhhs/mecdc/health-professionals/health-advisory-notices/maine-childhood-immunization-recommendations-wed

Maryland: https://health.maryland.gov/newsroom/Pages/Statement-from-Secretary-Seshamani-on-childhood-vaccine-schedule-.aspx

Massachusetts: https://www.mass.gov/news/governor-healey-condemns-cdc-rollback-of-childhood-vaccine-recommendations

Michigan: https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2026/01/06/vaccines-state

Minnesota: https://www.health.state.mn.us/news/pressrel/2026/immuniz010826.html

Mississippi: https://msdh.ms.gov/msdhsite/_static/resources/21461.pdf

New Hampshire: https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents2/han-child-immunization-schedule.pdf

New Jersey: https://www.nj.gov/health/news/2026/approved/20260112a.shtml

New Mexico: https://www.nmhealth.org/news/awareness/2026/1/?view=2309

New York: https://www.health.ny.gov/press/releases/2026/2026-01-12_pediatrics_vaccine_schedule.htm

North Carolina: https://www.ncdhhs.gov/blog/2026/01/08/ncdhhs-hosts-media-availability-discuss-importance-vaccines-and-address-recent-public-health

Oregon: https://www.cdph.ca.gov/Programs/OPA/Pages/NR26-001.aspx

Pennsylvania: https://www.pa.gov/agencies/health/newsroom/federal-changes-do-not-impact-vaccine-access–recommendations

Rhode Island: https://www.ri.gov/press/view/50302

Vermont: https://www.healthvermont.gov/disease-control/immunizations/recommended-vaccines-children-and-teens; https://www.health.ny.gov/press/releases/2026/2026-01-12_pediatrics_vaccine_schedule.htm

Washington: https://www.cdph.ca.gov/Programs/OPA/Pages/NR26-001.aspx

Wisconsin: https://www.dhs.wisconsin.gov/dph/memos/communicable-diseases/bcd-2026-01.pdf

  1. One exception is Virginia, which just swore in a new Democratic Governor on January 17th and may choose to change their position regarding vaccine recommendations soon. ↩︎
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VOLUME 38

AI Health Tools Raise Safety Concerns. Plus, Flu Vaccine Myths Spread During Record Season

Irving Washington , Hagere Yilma , and Joel Luther

Highlights

New features from AI companies, like ChatGPT Health and Claude for Healthcare, aim to provide personalized health guidance as OpenAI reports more than 40 million daily users seek health information from its chatbot, but concerns remain about AI providing wrong or dangerous health advice, particularly around mental health.

And as the U.S. experiences its highest flu levels in 25 years, a vaccine-strain mismatch may be contributing to claims that flu vaccines are ineffective, despite evidence that vaccines still reduce severe illness and death and protect against other circulating strains.

AI & Emerging Technology

AI Companies Launch Health Products as Millions Seek Medical Advice From AI

A laptop screen screen displaying a list is viewed over the shoulders of two people comparing it to a paper bill held in hand.
KFF/ Getty Images

What’s happening?

  • Two artificial intelligence (AI) companies announced new health-related features this month, with “ChatGPT Health” and “Claude for Healthcare” both allowing users to connect their medical records and wellness apps to the chatbots for personalized health guidance. The companies say the features are not intended to be used for diagnosis or treatment, but rather aim to help users navigate everyday health questions by grounding responses in users’ own health data.
  • The new tools come as OpenAI reports that more than 40 million people globally turn to ChatGPT daily for health information, with users asking 1.6 to 1.9 million health insurance questions per week about comparing plans, handling claims, billing, and coverage. According to a report from OpenAI which draws from anonymized conversations and a survey of ChatGPT users, Americans are using ChatGPT to decode medical bills, appeal insurance denials, and at times self-diagnose or manage their care. More than 5% of all ChatGPT messages globally are about health care, according to OpenAI’s report. KFF will continue to monitor how the public reports using AI tools for health information.

Why this matters

  • ChatGPT and other generative AI models can give wrong and potentially dangerous advice, particularly in conversations about mental health. OpenAI faces multiple lawsuits from people who say loved ones harmed or killed themselves after interacting with the tool, and several states have passed laws banning chatbots from providing mental health and therapeutic decision making.
  • KFF polling has shown that only about one in three adults (32%) say they would trust an online health tool that uses AI to access their medical records to provide personalized health information. Despite this low level of trust, the use of AI chatbots for health questions and the expansion into more personalized health features by leading AI companies suggests that the convenience offered by these tools may outweigh concerns about accuracy and safety, or that some users may not be aware of gaps in these areas. Health communicators and providers should be aware of how patients are using these tools and provide guidance on their appropriate use.

Social Media and AI Policy Roundup

Study Shows Team-Based Content Moderation Improves Consensus

A common challenge in content moderation of incorrect or harmful information is people do not agree on what is true. A December study from the Annenberg School for Communication found that content moderators working in teams reached higher levels of agreement on controversial content moderation decisions compared to working alone. The experiment involved over 600 politically diverse moderators and found that “structured social interaction” strengthened accuracy and agreement in content moderation decisions. The findings come as some major platforms have scaled back content moderation efforts to prioritize free speech and diverse thinking, with Meta ending its third-party fact-checking program in 2025 and X reducing its trust and safety teams. Even before these changes, a 2023 KFF poll found that most adults (69%) said social media companies were not doing enough to limit the spread of false and inaccurate health information.

Visa Restrictions Target Content Moderators and Fact-Checkers

A December directive from the State Department instructed immigration officers to deny H-1B visas to individuals who worked in fact-checking, content moderation, trust and safety, or other activities the administration considers censorship of Americans’ speech. In response, the International Fact-Checking Network issued a statement calling the policy a misunderstanding of fact-checking, arguing that the practice strengthens public debate rather than censoring it. Imran Ahmed, the CEO of the Center for Countering Digital Hate, was among European figures barred from receiving a visa and has sued the Trump administration, claiming the denial is “punishment” for his organization’s work combatting misinformation.

Reports indicate that X’s Grok chatbot is being used to create AI-generated nonconsensual intimate imagery (NCII) of women and children, which can harm victims’ mental health through depression, anxiety, PTSD, and suicidal ideation. X has since announced that it would restrict Grok from generating explicit images of real people in jurisdictions where such content is illegal, but these reports have raised questions about who is liable when AI causes documented psychological harm. International regulators have warned of investigations and other actions, and lawmakers in the U.S. have expressed concern. Legal observers have characterized the AI-generated images as a testing ground for whether Section 230 of the Communications Decency Act, which provides legal immunity to online platforms for user-generated content, extends to harmful or illegal AI-generated content. Legal efforts to regulate AI have largely stalled in the U.S., but a bill signed into law last year criminalizes sharing NCII, including AI-generated images, and requires platforms to remove them.

Recent Developments

Flu Vaccine Misconceptions Spread During One of the Worst Flu Seasons in Decades

A woman wearing a cloth mask receives a bandage on her shoulder from a health care professional.
Lauren Bishop / CDC

What’s happening?

Misleading claims that flu vaccines are ineffective or weaken the immune system have circulated during the ongoing respiratory virus season, which has seen the highest flu levels in 25 years. The surge in cases is largely driven by a new mutation of the virus, called subclade K, that emerged after the season’s vaccine formulation was finalized in March. Each year, scientists predict what strains to include in the coming season’s flu vaccine, but subclade K only became the dominant strain after those decisions were made, creating a mismatch between the vaccine and the circulating virus.

Where confusion about flu vaccines is emerging

  • The vaccine-strain mismatch may be contributing to claims that the vaccine is ineffective. Senator Rand Paul, for example, questioned the vaccine’s effectiveness on a podcast in mid-January, specifically citing the strain mismatch and suggesting that claims about crossover protection are “inflated.” While this season’s vaccine was not specifically designed to target subclade K, evidence from prior influenza seasons shows that flu vaccines can still provide some protection from infection when they are mismatched to the dominant circulating strain. Vaccination also helps to protect against severe outcomes, including hospitalization and death.
  • Statements by health officials may also contribute to concern over the safety of the flu vaccine. For example, a video clip of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. appearing on a podcast in 2020 has been shared widely online recently. In the clip, Kennedy says he would not take a flu shot “in a million years” and claims that the vaccine can make people susceptible to other infections. Other HHS officials have claimed that randomized controlled trials do not show that the flu vaccine protects against influenza, but fact-checkers note that flu vaccines are designed primarily to reduce the risk of hospitalization and death. Although clinical trials are typically too small to reliably measure these relatively rare outcomes, meta-analyses have demonstrated that flu vaccines reduce these risks.
  • Others have claimed that the flu vaccine increases the risk of being infected with flu. While flu vaccines can cause some side effects that may resemble flu-like illness, they contain inactivated or attenuated versions of the virus that cannot cause flu infection, and vaccination is not associated with higher rates of other, non-influenza infections. Because flu vaccines do not fully protect against infection and multiple strains can circulate in the same season, vaccinated individuals can still become infected with influenza, but this does not mean the vaccine caused the infection.

Conflicting guidance may contribute to further confusion

  • Guidelines published by the Centers for Disease Control and Prevention (CDC) in August 2025 recommended that everyone aged six months or older receive routine annual influenza immunization. However, as part of broader changes to federal vaccine policy, HHS issued a memo in January reducing the number of vaccines recommended for all children and moving six vaccines, including influenza, from routine recommendations to “shared clinical decision making,” a process where health care providers and parents decide individually whether vaccination is appropriate.
  • Physician organizations, including the American Medical Association (AMA) and American Academy of Pediatrics (AAP), have criticized the changes and reaffirmed their support for routine childhood vaccinations, including flu vaccines. KFF polling has shown that larger shares of the public trust their own health care providers and physician associations like the AMA and AAP than the CDC for reliable vaccine information.

Why this matters

  • The misleading narratives about flu vaccines and the shifting federal guidance come as flu vaccination rates have already declined from pre-pandemic levels to around 43% for both adults and children. Older adults, pregnant people, and people with underlying health conditions face the highest risk of severe illness, hospitalization, or death from influenza. While these groups typically have higher flu vaccination rates than the general public, the ongoing severe season and the vaccine-strain mismatch may create an environment that allows misleading claims about the flu vaccine to spread, potentially impacting vaccine uptake and hesitancy among these vulnerable groups.
  • For children, the federal government’s decision to move pediatric flu vaccines to the shared clinical decision making category could introduce additional barriers to vaccine access and potentially result in lower vaccination rates. The move comes as smaller shares of parents view flu vaccination as important. The KFF/Washington Post Survey of Parents found that while about nine in ten parents view routine immunizations for measles, mumps, and rubella (MMR) and polio as important for children in their community to get, a much smaller share (56%) said the same for the flu vaccine. Similarly, while at least eight in ten parents express confidence in the safety of MMR and polio vaccines for children, smaller shares (65%) say they are confident the flu vaccines are safe for children. HHS framed the decision as part of an effort to restore trust, but it remains unclear what effect the changes will have. KFF will continue to monitor how changing federal guidance impacts trust in vaccines and public health efforts.

More From KFF

About The Health Information and Trust Initiative: the Health Information and Trust Initiative is a KFF program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem. Our goal is to be of service to everyone working on health misinformation, strengthen efforts to counter misinformation, and build trust. 

View all KFF Monitors

The Monitor is a report from KFF’s Health Information and Trust initiative that focuses on recent developments in health information. It’s free and published twice a month.

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Support for the Health Information and Trust initiative is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF and KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities. The data shared in the Monitor is sourced through media monitoring research conducted by KFF.

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Quiz: Test Your Knowledge of the Affordable Care Act

Published: Jan 21, 2026

The Affordable Care Act (ACA) affects virtually all aspects of the U.S. health system, including insurers, providers, state governments, employers, taxpayers, and consumers. The ACA introduced regulated health insurance exchange markets, or Marketplaces, which offer financial assistance for ACA-compliant coverage to those without traditional insurance sources.

Take this ten-question quiz to see how much you know about how the ACA affects health insurance coverage and costs as well as who is eligible for financial assistance.

This field is for validation purposes and should be left unchanged.
Question 1 of 10
Which insurer practices were explicitly banned by the ACA in the individual and small-group markets?
Question 2 of 10
Which factors can ACA Marketplace insurers use to charge one person a different premium than another?
Question 3 of 10
Which populations saw the largest premium reductions in dollars on average as a result of the ACA Marketplace’s enhanced premium tax credits, which were established in 2021 and expired at the end of 2025?
Question 4 of 10
What share of ACA Marketplace enrollees received some form of tax credit in 2025?
Question 5 of 10
Tax credits are calculated based on the cost of the premium for a benchmark plan. What is a benchmark plan?
Question 6 of 10
When enhanced premium tax credits expired at the end of 2025, how much did average annual premium payments increase for enrollees to keep the same plan?
Question 7 of 10
The ACA requires insurers to offer plans with reduced patient cost-sharing reductions (CSRs), e.g., such as deductibles and copays to certain Marketplace enrollees with the purchase of a silver plan. Who is eligible for CSRs?
Question 8 of 10
Which components of the ACA have been changed due to a Supreme Court ruling?
Question 9 of 10
How much has ACA Marketplace enrollment changed in the last five years?
Question 10 of 10
As of January 1, 2027, which immigrants are eligible for ACA Marketplace coverage and tax credits?

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Medicaid Coverage of and Spending on GLP-1s

Published: Jan 16, 2026

GLP-1 (glucagon-like peptide-1) drugs were originally developed to help people with type 2 diabetes manage blood sugar levels but have gained widespread attention for their effectiveness as a treatment for obesity. Due to their cost, however, coverage of GLP-1s for obesity treatment in Medicaid, ACA Marketplace plans, and most large employer firms remains limited, and GLP-1 coverage in Medicare for treatment of obesity is prohibited under current law. While state Medicaid programs must cover nearly all Food and Drug Administration (FDA) approved drugs, a long-standing statutory exception allows states to choose whether to cover weight-loss drugs under Medicaid. As a result, Medicaid coverage of GLP-1 drugs for obesity treatment is optional for states, while coverage for other indications (diabetes, cardiovascular disease, and sleep apnea) is required.

The upfront costs of GLP-1s are an ongoing concern for both public and private payers, and some employers and state Medicaid programs are now restricting coverage, despite recognizing their effectiveness at treating obesity. Expanded obesity drug coverage can increase Medicaid spending and put pressure on overall state budgets, and states are now facing tighter budget conditions and longer-term fiscal uncertainty, due in part to the federal Medicaid cuts in the 2025 reconciliation law, causing state Medicaid programs to re-evaluate their obesity drug coverage. However, almost four in ten adults and a quarter of children with Medicaid have obesity, meaning expanding Medicaid coverage of these drugs could provide access to effective obesity treatments for millions. In the longer term, reduced obesity rates among Medicaid enrollees could also result in reduced Medicaid spending on chronic diseases associated with obesity, though the evidence is mixed. Any savings on health spending because of obesity drugs may take many years and may not accrue to the Medicaid program if individuals experience shifts in coverage, so states may not be factoring long-term savings into coverage decisions.

At the federal level, the Trump administration decided not to proceed with a Biden administration proposal to allow Medicare and require Medicaid to cover obesity drugs but recently launched their own obesity drug coverage initiatives to reduce costs and increase access (see Box 1). While lower prices for state Medicaid programs could help alleviate cost concerns for states and result in expanded coverage of obesity drugs, how the new lower costs compare to the net prices state Medicaid programs currently pay and how states will respond amid tightening budget conditions remain unclear. Further, the recent announcements will not impact costs for Medicaid enrollees as they already pay little or no copays for prescription drugs, and the costs of purchasing drugs directly from manufacturers through TrumpRx will likely still be prohibitive for people on Medicaid who must have a low income to qualify for the program. Unless Medicaid covers obesity medications, enrollees are unlikely to have access to them given the high out-of-pocket cost even at lower prices. 

This brief discusses the current landscape of Medicaid GLP-1 coverage and examines recent trends in Medicaid prescriptions and gross spending on GLP-1s. Key takeaways include:

  • Obesity drug coverage in Medicaid remains limited, with 13 state Medicaid programs covering GLP-1s for obesity treatment under fee-for-service (FFS) as of January 2026.
  • The number of Medicaid prescriptions and gross spending on GLP-1s have both increased substantially since 2019.
  • Increased utilization of Ozempic and Wegovy (semaglutide) as well as Mounjaro and Zepbound (tirzepatide) have contributed substantially to recent growth.

Box 1: Recent Trump Administration Obesity Drug Initiatives

In November 2025, the Trump administration announced reaching a deal with Eli Lilly and Novo Nordisk to lower the cost of their GLP-1s for Medicare, Medicaid, and those purchasing the drugs directly from the manufacturers through a new TrumpRx website. In December 2025, the administration also introduced the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) model, a five year CMS Innovation Center (CMMI) model that intends to expand access to obesity drugs in Medicaid and Medicare by negotiating lower GLP-1 prices with manufacturers. The new model will include standardized coverage criteria as well as lifestyle supports and is voluntary for state Medicaid programs, Medicare Part D plans, and manufacturers. State Medicaid programs and manufacturers were requested to submit their intentions to participate by January 8, 2026, and the model is expected to begin in May 2026. For Medicare Part D, this model will be implemented in January 2027, following a separate short-term demonstration that will allow Medicare Part D enrollees to access obesity drugs beginning in July 2026.

Does Medicaid cover GLP-1s for obesity treatment?

States can decide whether to cover obesity drugs under Medicaid. Under the Medicaid Drug Rebate Program, Medicaid programs must cover nearly all of a participating manufacturer’s FDA-approved drugs for medically accepted indications. However, weight-loss drugs are included in a small group of drugs that can be excluded from coverage1 (though the statutory exception refers to agents used for “weight loss”, “obesity drugs” is used to refer to this group of medications in this analysis). As a result, coverage of GLP-1 drugs for the treatment of obesity remains optional for states, while coverage is required for drugs approved for the treatment of diabetes and, since March 2024 and December 2024, for the treatment of cardiovascular disease (Wegovy) and moderate to severe obstructive sleep apnea in adults with obesity (Zepbound), respectively (Table 1). Coverage is also required if deemed medically necessary for children under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

Obesity drug coverage in Medicaid remains limited, with 13 state Medicaid programs covering GLP-1s for obesity treatment under FFS as of January 2026 (Figure 1). When covered, GLP-1s are typically subject to utilization controls such as prior authorization, which can further limit access. Notably, KFF’s 2025 Medicaid budget survey found 16 state Medicaid programs covered GLP-1s for obesity treatment as of October 2025; however, since then, four states (California, New Hampshire, Pennsylvania, and South Carolina) have eliminated coverage of GLP-1s for obesity treatment, likely reflecting recent state budget challenges and the significant costs associated with coverage. North Carolina eliminated GLP-1 coverage beginning October 2025 due to a budget stalemate in the legislature, but coverage was reinstated in December 2025, bringing the total number of states covering GLP-1s for obesity to 13 as of January 2026. A few other states are planning or considering obesity drug restrictions in state fiscal year 2026 or 2027, and state interest in expanding coverage of obesity drugs is also waning according to this year’s survey, with states continuing to report cost as the key factor contributing to obesity drug coverage decisions. The state obesity drug coverage landscape will continue to evolve as states respond to the recent announcement of the BALANCE model (see Box 1) and as states contend with budget challenges and the federal Medicaid spending cuts in the 2025 reconciliation law.

13 State Medicaid Programs Covered GLP-1s for Obesity Treatment Under Fee-for-Service as of January 2026

How have Medicaid prescriptions and gross spending on GLP-1s changed in recent years?

The number of Medicaid prescriptions and gross spending on GLP-1s have increased substantially since 2019 (Figure 2). Not all GLP-1s are approved for obesity treatment, and this analysis includes all FDA-approved GLP-1s, including those approved for obesity (Saxenda, Weogvy, Zepbound) as well as those approved for type 2 diabetes (see Table 1). Overall, the number of GLP-1 prescriptions increased sevenfold, from about 1 million in 2019 to over 8 million in 2024. At the same time, gross spending increased ninefold, from about $1 billion in 2019 to almost $9 billion in 2024, and gross spending per GLP-1 prescription reached $1,000 in 2024. Preliminary trends through June 2025 (data not shown) show rapid growth will continue in 2025. Those prices and spending numbers do not account for rebates, and states typically receive substantial rebates on brand drugs. In response to growing criticism of the cost of their drugs, Novo Nordisk, the company that manufactures Ozempic and Wegovy, reported last year that rebates and other fees (across all payers) accounted for about 40% of the cost of the two drugs and that they expected rebates to grow. GLP-1s still account for a relatively small share of the total number of Medicaid prescriptions, accounting for about 1% of all Medicaid prescriptions in 2024 (up from about 0% in 2019). However, GLP-1s accounted for over 8% of all Medicaid prescription drug spending before rebates in 2024 (up from 1% in 2019).

Medicaid Prescriptions and Gross Spending on GLP-1s Have Increased Substantially Since 2019

Specifically, increased utilization of Ozempic and Wegovy (semaglutide) as well as Mounjaro and Zepbound (tirzepatide) have contributed substantially to recent growth. Prescriptions and spending on Ozempic, approved for type 2 diabetes (not obesity) in 2017, have grown considerably over the period. By 2024, Ozempic had surpassed Trulicity, also approved for type 2 diabetes (not obesity) to make up the largest share of GLP-1 prescriptions and spending (39% in 2024). Looking from 2023 to 2024, the latest year of data available, prescriptions and gross spending for Wegovy (first approved for obesity in 2021, approved for cardiovascular disease in 2024) and Mounjaro (approved for type 2 diabetes in 2022) more than doubled, and prescriptions and gross spending for Zepbound (first approved for obesity in 2023, approved for sleep apnea in 2024) increased more than fivefold. These drugs are produced by Novo Nordisk and Eli Lilly, which both recently announced agreements with the Trump administration to lower prices. From Medicaid data publicly available, there is no way yet to disentangle how much of the growing use of GLP-1s is related to treatment for diabetes, cardiovascular disease, or sleep apnea versus obesity, or a combination.

U.S. FDA Approvals of GLP-1s

Methods

Number of Prescriptions and Gross Spending Data: This analysis uses 2019 through 2024 State Drug Utilization Data (SDUD) (downloaded in January 2026). The SDUD is publicly available data provided as part of the Medicaid Drug Rebate Program (MDRP), and provides information on the number of prescriptions, Medicaid spending before rebates, and cost-sharing for rebate-eligible Medicaid outpatient drugs by NDC, quarter, managed care or fee-for-service, and state. It also provides this data summarized for the whole country. The data do not include information on the number of days supplied in each prescription. CMS has suppressed SDUD cells with fewer than 11 prescriptions, citing the Federal Privacy Act and the HIPAA Privacy Rule. This analysis used the national totals data because less data is suppressed at the national versus state level.

Identifying GLP-1s: This analysis includes all Medicaid prescriptions and gross spending for any FDA-approved GLP-1s. KFF links each drug’s NDC in the dataset to a drug class using the World Health Organization’s (WHO) Anatomical Therapeutic Chemical (ATC) classification system. GLP-1s are then identified as those classified under “A10BJ” or glucagon-like peptide-1 (GLP-1) analogues. The analysis also includes tirzepatide (Mounjaro and Zepbound), which is a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 agonist (and classified under “A10BX” or other blood glucose lowering drugs, excl. insulins). This method results in the inclusion of Medicaid prescriptions and gross spending for: Ozempic, Rybelsus, Mounjaro, Victoza, Trulicity, Wegovy, Zepbound, Saxenda, and generic liraglutide as well as a small number of prescriptions and spending for Adlyxin, Byetta, Bydureon BCise, and Tanzeum (now discontinued).  

Limitations: There are a few limitations to the estimates of Medicaid prescriptions and gross spending found in this analysis, including:

  • This analysis examines the number of Medicaid prescriptions in the data and does not adjust for days supplied by each prescription.
  • Gross spending and spending per prescription numbers do not account for rebates.
  • The SDUD are updated quarterly; a new quarter of data is typically released, and the prior five years of data are also updated. This means utilization and gross spending totals can vary depending on when the data is downloaded, and totals may not match other outside sources or prior KFF analysis for this reason.
  1. Drugs that may be excluded from coverage under the MDRP include drugs used for: a) anorexia, weight loss, or weight gain, b) promoting fertility, c) cosmetic purposes or hair growth, d) symptomatic relief of cough and colds, e) prescription vitamins and mineral products except prenatal vitamins and fluoride preparations , f) nonprescription drugs, g) a manufacturer’s covered outpatient drug in which tests and monitoring services have to be purchased from that manufacturer, h) sexual or erectile dysfunction unless used to treat a condition. For more information see, 42 U.S.C. § 1396r-8.  ↩︎
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Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State

Published: Jan 14, 2026
Section:
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Tracker

Section 1115 Medicaid demonstration waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute, if [in the HHS Secretary’s view] the approach is likely to “promote the objectives of the Medicaid program.” They can provide states additional flexibility in how they operate their programs, beyond the considerable flexibility that is available under current law. Waivers generally reflect priorities identified by states as well as changing priorities from one presidential administration to another. Nearly all states have at least one active Section 1115 waiver and some states have multiple 1115 waivers. See the “Key Themes Maps” tab for a discussion of recent waiver trends.

This page tracks approved and pending Section 1115 waiver provisions (including expansions and restrictions) related to eligibility, benefits, and social determinants of health and other delivery system reforms, once such waivers are posted to the state waivers list on Medicaid.gov. For more information on inclusion criteria and on each provision, as well as a list of acronyms, see the Definitions tab.

Detailed Topic Tables

Aggregate State Tables

Landscape of Approved and Pending Section 1115 Waivers

 

Waivers with Eligibility Changes

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Waivers with Benefit Changes

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Waivers with SDOH & Other DSR Changes

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All Approved Waivers by Topic

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Approved Section 1115 Medicaid Waivers

All Pending Waivers by Topic

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Pending Section 1115 Medicaid Waivers

Work Requirements

See KFF’s Work Requirements Tracker for additional state and national-level data related to work requirement implementation, including related KFF resources on work requirements.

The 2025 reconciliation law requires states to condition Medicaid eligibility for adults in the ACA Medicaid expansion group on meeting work requirements starting January 1, 2027; however, states have the option to implement requirements sooner through a state plan amendment or through an approved 1115 waiver.

State Plan Amendments

Some states may choose to implement work requirements prior to the January 1, 2027 deadline through a state plan amendment. Nebraska is the first state to have announced that it will begin enforcing federal work requirements early through a state plan amendment, starting May 1, 2026.

1115 Waivers

States may also choose to implement work requirements early through an 1115 waiver. Since the start of the second Trump administration, several states have submitted waivers to implement work requirements, although some states may no longer be moving forward with proposed 1115 waivers due to the passage of federal work requirements or because they plan to implement early through a state plan amendment. While states are required to fully align with federal work requirements starting January 1, 2027, it is not clear how CMS will treat pending 1115 waivers that seek to implement early and deviate from federal requirements (specified in the law) prior to this deadline.

Currently, Georgia is the only state with a Medicaid work requirement waiver in place following litigation over the Biden administration’s attempt to stop it. CMS recently approved a temporary extension for Georgia’s waiver that added new exemptions from work requirements (see the table below for more details). Georgia’s waiver is now set to expire December 31, 2026, and the state will be required to come fully into compliance with new federal requirements starting January 1, 2027.

Early Implementation and Waiver Status

The map below identifies states that have indicated they will implement work requirements early through a state plan amendment as well as approved (Georgia) and pending work requirement waivers (submitted to CMS since the start of the second Trump administration). The table below the map provides more detailed state waiver information.

States Implementing Work Requirements Early and/or Pursuing Work Requirement Waivers

Key States with Work Requirement Waiver Activity

Key Themes Maps

Section 1115 waivers generally reflect priorities identified by states as well as changing priorities from one presidential administration to another.  Key Biden administration 1115 initiatives included waivers addressing enrollee health-related social needs (HRSN), pre-release coverage for individuals who are incarcerated, and multi-year continuous eligibility for children.

In March 2025, the Trump administration rescinded HRSN guidance issued by the Biden administration. CMS indicates this does not nullify existing HRSN 1115 approvals but going forward they will consider HRSN / SDOH requests on a case-by-case basis. In April 2025, the Trump administration announced it would be phasing out federal funding for “Designated State Health Programs” (DSHP) in waivers. In July 2025, the Trump administration released guidance indicating it will not approve (new) or extend (existing) continuous eligibility waivers for children or adults. CMS also announced in July it would be phasing out initiatives to strengthen the Medicaid workforce for primary care, behavioral health, dental, and home and community based services (not depicted in maps below).

This page tracks pending and approved waivers in key areas of recent state activity and will track Trump administration action in these areas going forward. Hover over individual states to display waiver expiration dates.

Social Determinants of Health

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work and age. SDOH include but are not limited to housing, food, education, employment, healthy behaviors, transportation, and personal safety. In 2022, CMS (under the Biden administration) announced a demonstration waiver opportunity to expand the tools available to states to address enrollee “health-related social needs” (or “HRSN”) including housing instability, homelessness, and nutrition insecurity, building on CMS’s 2021 guidance. In 2023, CMS issued a detailed Medicaid and CHIP HRSN Framework accompanied by an Informational Bulletin, which were updated in 2024.

In March 2025, the Trump administration rescinded the Biden administration HRSN guidance. CMS indicates this does not nullify existing HRSN approvals but going forward they will consider HRSN / SDOH requests on a case-by-case basis.

The “HRSN Waivers” map below identifies states with approval under the Biden administration HRSN framework. The “All SDOH Waivers” map identifies SDOH-related 1115 waivers more broadly, including those that pre-date or were approved outside of the HRSN framework. For more detailed waiver information, refer to KFF’s Medicaid Waiver Tracker (“SDOH” table) and HRSN waiver watch  (March 2024).

Section 1115 Waivers: Social Determinants of Health (SDOH)

Medicaid Pre-release Coverage for Individuals Who Are Incarcerated

In April 2023, the Biden administration released guidance encouraging states to apply for a new Section 1115 demonstration opportunity to test transition-related strategies to support community reentry for people who are incarcerated. This demonstration allows states a partial waiver of the inmate exclusion policy, which prohibits Medicaid from paying for services provided during incarceration (except for inpatient services). Reentry services aim to improve care transitions and increase continuity of health coverage, reduce disruptions in care, improve health outcomes, and reduce recidivism rates. The Biden administration approved 19 state waivers to facilitate reentry for individuals who are incarcerated. The map below identifies states with approved and pending waivers to provide pre-release services to Medicaid-eligible individuals who are incarcerated.  Medicaid pre-release waivers have been pursued by both Republican and Democratic governors. For more information, refer to KFF’s Medicaid Waiver Tracker (“Eligibility Changes” table) and related pre-release waiver watch (August 2024).

Section 1115 Waivers: Medicaid Pre-release Coverage for Individuals Who Are Incarcerated

Multi-year Continuous Eligibility for Children

The Consolidated Appropriations Act, 2023 required all states to implement 12-month continuous eligibility for children beginning on January 1, 2024. The Biden administration approved 9 waivers that allow states to provide multi-year continuous eligibility for children (e.g., from birth to age six). Continuous eligibility has been shown to reduce Medicaid disenrollment and “churn” rates (rates of individuals temporarily losing Medicaid coverage and then re-enrolling within a short period of time).

In July 2025, the Trump administration released guidance indicating it will not approve (new) or extend (existing) continuous eligibility waivers for children or adults. The map below displays states with waiver approval to provide multi-year continuous eligibility for children.  For more information, refer to KFF’s Medicaid Waiver Tracker (“Eligibility Changes” table) and related continuous eligibility waiver watch (February 2024).

Section 1115 Waivers: Multi-year Continuous Eligibility for Children

Definitions

Section 1115 Waiver Tracker: Key Definitions and Notes

Related Resources

Recent Developments

General/Overview Resource

Eligibility and Enrollment Expansions

Eligibility and Enrollment Restrictions

Work Requirements:

Other:

Benefit Expansions

Benefit Restrictions, Copays, and Healthy Behaviors

Social Determinants of Health

Delivery System Reform

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Medicaid State Health Policy and Data Medicaid Work Requirements Waivers