Key Takeaways

• The cost of health care, including paying for health insurance and out-of-pocket expenses, tops the list of the public’s economic anxieties, rising well above other necessities. Two-thirds of the public (66%) say they worry about being able to afford health care for them and their family, ranking higher than utilities, food and groceries, housing, and gas. In addition, most adults (55%) say their health care costs have gone up in the past year, including at least one in five who say they have increased at a faster rate than food or utilities. A majority (56%) of the public say they expect health care costs for them and their families to become even less affordable in the coming year.
• With health care costs topping the list of economic worries across partisans and key groups, voters expect the issue to play a major role in their decisions to turnout in November’s midterm elections as well as which candidates they support. Majorities across partisans say health care costs will impact their vote in November, but the issue is resonating more with Democratic voters and independent voters. More than three-quarters of Democratic voters and independent voters say health care costs will impact both their decision to vote and which party’s candidate they will vote for in the election, compared to about half of Republican voters. In fact, two-thirds of Democratic voters and more than four in ten independent voters say health care costs will have a “major impact” on their 2026 voting decisions.
• The Democratic Party has the advantage when it comes to which party voters trust to handle most health care issues, including health care costs, on which the Democrats have a 13-point advantage over Republicans. The one exception is prescription drug prices, an issue President Trump has focused on in his second term, and on which similar shares of voters say they trust the Democratic Party (35%) and the Republican Party (30%). Among independent voters, the Democratic Party has an edge over the Republican Party on health care issues, but many independent voters also say they don’t trust either party.
• The public’s anxiety around health care costs comes at a time when the Senate and President Trump seem unlikely to revive the ACA enhanced premium tax credits, which expired on January 1^st. Most (67%) of the public say Congress did the “wrong thing” by not extending the credits, including large majorities of Democrats (89%) and independents (72%). But majorities of Republicans (63%) including MAGA supporters (64%) say Congress did the “right thing” by not extending the ACA enhanced premium tax credits. While overall popularity of the ACA and the Marketplaces is still high, given the recent debate around the ACA enhanced tax credit debates, favorability has declined among Republicans.

Health Care Costs Top Public’s Concerns During Moment of Economic Anxiety

One year into the second term of President Trump and less than ten months before the 2026 midterm elections, the public remains concerned about the top issue of the 2025 election – the economy. Eight in ten (82%) adults say their cost of living has increased in the past year, including half who say it has increased “a lot.” Very few say their cost of living has “decreased” either “a little” (4%) or “a lot” (1%) while about one in ten say their living expenses have remained stable over the past year. Many adults, regardless of partisanship, say their cost of living has increased “a lot” in the past year, including a majority of (56%) Democrats, about half (53%) independents, and four in ten (41%) Republicans. About four in ten (38%) supporters of the Make America Great Again Movement (MAGA) also say their cost of living has increased “a lot” in the past year.

Concerns about household spending coincide with a majority (71%) of the public saying President Trump is not focusing enough on domestic affairs, such as addressing the cost of living in the U.S. The share of the public who say President Trump is not paying enough attention to domestic concerns rises to about nine in ten (89%) Democrats and three-quarters of (76%) independents. On the other hand, a majority of the public (55%) also say the Trump administration is focusing “too much” on foreign affairs, such as actions in Venezuela, Ukraine, and Gaza. Republicans and MAGA supporters are more positive about President Trump’s priorities, with many saying he is spending the “right amount” on both domestic affairs (53% and 60%), and foreign affairs (66% and 76%).

The latest KFF Health Tracking Poll finds health care costs top the list of what the public worries about being able to afford for themselves and their family. Two-thirds (66%) of the public say they worry about paying for health care, including the cost of health insurance and out-of-pocket costs for things like office visits and prescription drugs, ranking higher as a financial worry than other household expenses like utilities, food, and rent or mortgage – all three items on which a majority of Americans are still worried about being able to afford.  About a third of adults (32%) say they are “very worried” about affording health care expenses, while about a quarter of adults say the same about being able to afford food and groceries (24%), their rent or mortgage (23%), or utilities (22%). About a fifth of adults say they are “very worried” about affording gas and transportation costs (17%). This comes as recent reports show that health care costs are on the rise for most Americans and the Affordable Care Act (ACA) enhanced tax credits, which benefitted most people who purchased insurance through the marketplace, have expired.

Notably, health care costs are the biggest worry compared to other household expenses for all adults, regardless of partisanship. About one third of Democrats (36%) and Independents (34%) say they are “very” worried about affording health care, as are about one in four (24%) Republicans. This includes one in four MAGA Republicans (23%) and non-MAGA Republicans (24%).

One reason why health care expenses may be topping the list of household worries is that most adults say their health care costs have increased in the past year, including a substantial share who say these costs have increased at a faster rate than other household expenses.

Overall, more than half (55%) of adults say their health care costs have increased in the past year. This includes about two-thirds of people with employer-based health insurance (64%) and those who purchase their own coverage (66%), as well as about half (53%) of Medicare enrollees 65 and older. Perceptions about the increase of health care costs persist across partisanship, with about half or more across partisans saying their health care costs have increased in the past year, including 58% of Democrats, 56% of independents, and 51% of Republicans, including 47% of MAGA Republicans.

Notably, about one in five of all adults say their health care costs have increased at a faster rate than other necessities like utilities (23%) and food and groceries (21%). This includes similar shares among partisans and MAGA supporters, as well as at least one in four with employer-sponsored insurance and about a third who purchase their own insurance. Smaller shares of adults who receive health insurance through Medicaid and Medicare say their health care costs have increased at a faster rate than utilities and food and groceries, suggesting those with government coverage are more insulated from the rising cost of health care.

Looking ahead to the next year, a majority (56%) of adults expect their family’s health care costs to become less affordable, while about a third (35%) expect them to stay about the same, and one in ten (9%) expect them to be more affordable. Most Democrats (62%) and independents (58%) expect health care costs to become less affordable, while Republicans, including those who identify as MAGA Republicans are split, with similar shares saying they expect them to become less affordable or expect them to say about the same. Majorities across insurance types expect their health care costs to become less affordable. This includes two-thirds of those who self-purchase (64%) or have employer-sponsored insurance (60%) and majorities of those who are uninsured (57%) or who have coverage through Medicaid (55%).

Democrats Have an Advantage on Health Care Issues, But No Party Has an Advantage on the Cost of Living 

With health care costs on the rise and a significant source of worry for many, a majority of voters, regardless of partisanship, say the issue will play a role in their voting decisions. The cost of health care is a particularly strong motivator for Democratic voters, of whom more than eight in ten say it will impact their decision to vote and who they will vote for, including two-thirds who say it will have a “major impact.” The cost of health care is a similarly large motivator for independents, of whom about eight in ten say it will impact their vote, including more than four in ten who say it will have a “major impact.” While Democratic and independent voters are more likely to say health care costs are a strong motivator compared to Republican voters, substantial shares of Republican voters say it will impact their decisions in November as well. Six in ten (60%) Republican voters say it will impact their decision to vote and 56% say it will impact which party’s candidate they will vote for. This includes about a fifth of Republican voters who say the cost of health care will have a “major impact.” This suggests that rising health care costs resonate with voters across the board and will be a key voting issue to watch for in this November’s elections.

Less than ten months before the 2026 midterm elections, the Democratic Party has a strong edge over the Republican Party when it comes to health care issues, including on the cost of health care. Democrats have a double-digit advantage over the Republicans when it comes to who voters trust on determining the future of Medicaid (43% vs. 25%), addressing the future of the ACA (42% vs. 26%), determining the future of Medicare (40% vs. 26%), and addressing the cost of health care (40% vs. 27%). Voters are more divided on which party they trust to address the cost of prescription drugs, an issue that President Trump has focused on during his second term. Notably, on every health care issue asked about, at least a quarter of voters say they trust neither party to do a better job.

Unsurprisingly, on each health care issue polled, Democratic voters are more likely to say they trust the Democratic Party and Republican voters are more likely to say they trust the Republican Party. Among independent voters, the Democratic Party has a clear advantage over the Republican Party on each of the health care issues; however, sizeable shares of independent voters (between about one-third and four in ten) say they trust “neither” party. When it comes to addressing the cost of prescription drugs, a larger share of independent voters say they trust “neither party” than say they trust either the Democrats or the Republicans.

While the Democrats have an advantage among voters overall on health care issues, voter confidence is low when it comes to both political parties and President Trump to address the cost of living. Most voters say they have “not too much” confidence or “none” in the Republicans in Congress (64%), the Democrats in Congress (63%), and President Trump (61%), to address the cost of living for people like them. Small and similar shares of voters overall say they have “a lot” or “some” confidence in President Trump (38%), Democrats in Congress (37%), or Republicans in Congress (36%) to address the cost of living.

Amid the ACA Tax Credits Debate, Favorability of the ACA and ACA Marketplace Remains High, but Has Declined Among Republicans  

While a majority of the public continues to express a favorable view of the ACA, Republicans’ views have soured recently in the wake of the debate over extending the enhanced tax credits and Republican lawmakers’ persistent attacks on the 2010 health care law. Overall favorability of the ACA has dropped in the most recent poll, with 58% now saying they have a favorable view of the law and 41% saying they have an unfavorable view (down from 64% favorable, 35% unfavorable in September 2025). The overall decline in favorability of the ACA is driven by Republicans, of whom one in five (22%) now say they have a “very” or “somewhat” favorable view, compared to one-third (36%) who said the same in September. Views of the ACA remain positive and stable among Democrats (91%) and independents (62%), as well as among individuals who buy their own health coverage (64%).

Favorable views of the ACA marketplaces where people and small businesses owners can shop for health insurance have also declined from 70% in September 2025 to 62% in the latest KFF Health Tracking Poll. Similarly to views of the ACA overall, this shift is driven by Republicans (41% now vs. 59% in September 2025 who said they view the marketplace favorably). Views of the ACA marketplaces are stable and favorable among Democrats (81%), independents (64%), and among those who self-purchase their insurance (64%).

Most Say Congress Did the “Wrong Thing” Not Extending the ACA Tax Credits

The public is largely critical of Congress not extending the ACA enhanced tax credits for people who buy their own health coverage. Two-thirds of the public say Congress did the “wrong thing” by not extending the ACA enhanced tax credits, compared to one-third who say Congress did the “right thing.” Majorities of Democrats (89%), independents (72%), non-MAGA Republicans (54%), and those who purchase their insurance themselves (67%) say Congress did the “wrong thing” by not extending the tax credits. While most (63%) Republicans say Congress did the “right thing” by not extending the tax credits, a sizeable share, about four in ten (37%), say Congress did the “wrong thing.” This marks a shift in views from when debates over to extend the tax credits or not were still ongoing in November, when half of Republicans said Congress should extend the tax credits, suggesting the debates have shifted opinion among the Republican base.

Among those who think the enhanced tax credits should have been extended, a group that leans more Democratic, many say most of the blame either falls on President Trump (42%, 28% of total adults) or Republicans in Congress (38%, or 26% of total adults). About one in five (19%, or 13% of total adults) say Democrats in Congress deserve the most blame. Among the four in ten Republicans who say Congress did the “wrong thing” not extending the tax credits, two-thirds (64%) blame Democrats in Congress for their expiration, rising to seven in ten (72%) MAGA-supporters.

There are some indications that the expiration of the enhanced tax credits will play a role in how voters make decisions in the coming November election. Among those who self-purchase their insurance, two-thirds say it will impact their decision to vote (66%) and which party’s candidate they will vote for (67%) in the upcoming election. And although the expiring enhanced premium tax credits directly affect only those who purchase their own coverage on the ACA marketplaces, among voters overall, six in ten (62%) say their expiration will have an impact on their decision to vote, including 30% who say it will have a “major impact” and 31% who say it will have a “minor impact.” An additional four in ten (38%) voters say it will have “no impact at all” on their decision to vote. The expiration of the tax credits is a stronger motivator for Democratic voters and independent voters than for Republican voters. About eight in ten Democratic and two-thirds of independent voters say it will impact their voting behavior, compared to about four in ten Republican voters.

This KFF Health Tracking Poll/KFF Tracking Poll on Health Information and Trust was designed and analyzed by public opinion researchers at KFF. The survey was conducted January 13-20, 2026, online and by telephone among a nationally representative sample of 1,426 U.S. adults in English (n=1,355) and in Spanish (n=71). The sample includes 1,028 adults (n=60 in Spanish) reached through the SSRS Opinion Panel either online (n= 1,003) or over the phone (n=25). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails.

Another 398 (n=11 in Spanish) adults were reached through random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Among this prepaid cell phone component, 149 were interviewed by phone and 249 were invited to the web survey via short message service (SMS).

Respondents in the prepaid cell phone sample who were interviewed by phone received a $15 incentive via a check received by mail or an electronic gift card incentive. Respondents in the prepaid cell phone sample reached via SMS received a $10 electronic gift card incentive. SSRS Opinion Panel respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card). In order to ensure data quality, cases were removed if they failed two or more quality checks: (1) attention check questions in the online version of the questionnaire, (2) had over 30% item non-response, or (3) had a length less than one quarter of the mean length by mode. Based on this criterion, 2 cases was removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2025 Current Population Survey (CPS), September 2023 Volunteering and Civic Life Supplement data from the CPS, and the 2025 KFF Benchmarking Survey with ABS and prepaid cell phone samples. The demographic variables included in weighting for the general population sample are gender, age, education, race/ethnicity, region, civic engagement, frequency of internet use and political party identification. The weights account for differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available on request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

On January 27, 2026, the Trump administration released details of the latest expansion of the Mexico City Policy, a policy he reinstated in January of last year. The policy, which has been in effect, depending on the party of the President, since 1984, has required foreign non-governmental organizations (NGOs) to certify that they would 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. government global family planning funding. In 2017, President Trump reinstated the policy but also significantly expanded it to encompass the vast majority of U.S. bilateral global health assistance. The latest expansion, now part of a broader set of restrictions known as the “Promoting Human Flourishing in Foreign Assistance (PHFFA)” Policy, applies to significantly more funding, many more organizations, and new services and activities. Specifically, it now applies to most non-military foreign assistance and most recipients of foreign aid (not just foreign NGOs). And, in addition to abortion, it prohibits activities related to diversity, equity, and inclusion (DEI) and promoting or providing gender affirming care, legal protections based on gender identity, and other related services and activities. This analysis assesses the potential reach of the latest expansion of the policy by examining foreign assistance funding provided in FY 2024, the most recent year with complete information, to identify the amount of funding, number of organizations, and range of foreign assistance sectors that stand to be affected. The analysis looks at total funding that would be subject to restrictions, and although not all recipients are necessarily currently engaging in activities subject to the restrictions, all would have to decide whether they accept the policies’ terms. Among the key findings:

• In FY 2024, $39.8 billion in U.S. foreign aid, spanning 160 countries, was obligated to prime recipients, funding that would be subject to the latest expansion (additional funding could be subject to the policy if it was ultimately provided, directly or indirectly, to recipients or sub-recipients).
• Notably, this is tens of billions more than the amount of global health assistance subject to the policy under the Trump administration’s previously expanded policy ($7.3 billion in FY 2020), and significantly more than the amount of family planning assistance subject to the policy during earlier administrations (between $300-$600 million).
• By recipient type, the largest share (41%) of the $39.8 billion was provided to multilateral organizations, recipients that are newly subject to the policy under the latest expansion. The second largest (29%) was provided to private sector organizations, including the newly-subject U.S. private sector.
• By sector, humanitarian assistance accounted for the largest share of funding (29%), followed by health (26%) and economic development (22%); two of these sectors (humanitarian assistance and economic development) are among the several sectors newly subject to the policy under the latest expansion.
• There were almost 2,600 prime recipients of U.S. foreign aid in FY 2024, a significantly higher number than for health alone (756 prime recipients). This number should be considered a floor, since prime recipients must “flow-down” the policy to any sub-recipients. The majority of prime recipients were foreign entities (62%); U.S.-based entities accounted for 34%, with multilateral recipients accounting for 4%.
• Whether or not the full extent of the expansion will be instituted (there are likely to be legal challenges to some aspects of the policy, which could limit its reach, and some additional rule-making has yet to occur), it represents a significant expansion in terms of funding, number of organizations, and content and services restricted, well beyond the reach of what was in place during the first Trump administration.

Background

The Mexico City Policy (MCP) is a U.S. government (USG) policy that – when in effect – has required foreign NGOs¹ 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, in 2017 under the first 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 and has been in effect for 23 of the past 42 years. It has also been steadily expanded over time (see Table 1). Under the first Trump administration, the policy was renamed “Protecting Life in Global Health Assistance” (PLGHA). Among opponents, it has also been known as the “Global Gag Rule,” because among other activities, it prohibited foreign NGOs from using any funds (including non-U.S. funds) to provide information about abortion as a method of family planning and to lobby a foreign government to legalize abortion.

The second Trump administration reinstated the MCP through a Presidential Memorandum on January 24, 2025, noting that the policy would be expanded even further. On January 27, 2026, the policy details were released under three separate, but inter-related final rules (interim final rules were first posted on January 23), now called the “Promoting Human Flourishing in Foreign Assistance (PHFFA) Policy” (see Box 1).

This marks the most significant expansion of the policy to date. Specifically, it:

• expands to all non-military U.S. foreign assistance (not just global health) administered by the State Department² (with an intention for the State Department to work with other agencies that administer foreign assistance to also incorporate these provisions);
• expands the types of recipients, and consequently the number of organizations, subject to the policy to also include multilateral organizations, foreign governments, and U.S.-based NGOs (not just foreign NGOs);³
• expands to prohibit additional content areas and services newly subject to the policy: DEI-related activities as well as support for gender affirming care and services, information, and legal protections based on gender identity, among other related activities (referred to as promoting “gender ideology”); and
• expresses an intent to expand to include funding provided through contracts (not just grants and cooperative agreements), although this will be the subject of future rule-making.

Findings

To assess the potential reach of the latest expansion, this analysis looks at U.S. government foreign assistance obligation data for FY 2024 (the most recent year for which complete obligation data by sector are available) to quantify the amount of funding and number and type of prime recipients that could be affected. While not all recipients are necessarily currently engaging in activities subject to the restrictions, all would have to decide whether they accept the policies’ terms. Obligations were analyzed because the policy applies to funding once newly obligated to a recipient (either through an existing or a new award). Data were obtained from ForeignAssistance.gov, the U.S. government’s centralized data portal for budgetary and financial data provided by more than 20 federal agencies that manage foreign assistance programs. The analysis is based on the funding identified in the PHFAA rules, which includes all non-military foreign assistance⁴ appropriated to the State Department or U.S. Agency for International Development (USAID) under Title III and four other accounts under Department of State, Foreign Operations, and Related Programs (SFOPs)/National Security, State Department, and Related Programs (NSRP) appropriations acts (specifically, “International Narcotics Control and Law Enforcement,” “Nonproliferation, Anti-Terrorism, Demining and Related Programs,” “Peacekeeping Operations,” and “International Organizations and Programs”). The analysis also includes funding provided through contracts (not just grants and cooperative agreements) for two reasons: first, the rules indicate that further rule-making will be undertaken to add these policy restrictions to contracts; and second, it is not possible to disaggregate obligations by funding instrument in ForeignAssistance.gov (see Box 2 for key terms, Methodology for more detail, and Appendix for detailed data).

• In FY 2024, $39.8 billion in U.S. foreign aid was obligated to prime recipients, funding that would be subject to the latest expansion. This includes funding provided to U.S. and foreign NGOs, international organizations, foreign governments, and parastatals (additional funding could be affected if it was ultimately provided, directly or indirectly, to recipients or sub-recipients subject to the policy).
• Notably, this is tens of billions more than the amount of global health assistance subject to the policy under the first Trump administration’s previously expanded policy ($7.3 billion in FY 2020), and significantly more than the amount of family planning assistance subject to the policy during earlier administrations (between $300-$600 million). See Box 3.

• By recipient type, the largest share of funding was provided to multilateral organizations ($16.3 billion, or 41%), entities that are newly subject to the policy. The private sector received the next largest amount of funding ($11.4 billion, or 29%), followed by the non-profit sector ($9.7 billion, or 25%). Smaller amounts were provided to foreign governments ($1.3 billion, or 3.2%) and educational institutions ($1.1 billion, or 2.7%) (see Figure 1).
• U.S.-based recipients received $16.5 billion (41%). These included U.S. NGOs, specifically U.S. non-profits, private sector organizations, and educational institutions (all newly subject to the policy). Foreign recipients, both governments and NGOs, received $6.9 billion (17%); foreign governments are also newly subject to the policy.
• Collectively, the $39.8 billion in foreign assistance was provided to 160 countries, with more countries likely reached through “regional” and “worldwide” activities.⁷ This is significantly more countries than would be reached with global health assistance alone (87 countries).
• By sector, humanitarian assistance accounted for the largest share of funding ($11.5 billion, or 29%) in FY 2024, followed by health ($10.5 billion, or 26%) and economic development ($8.7 billion, or 22%). Two of these sectors (humanitarian assistance and economic development) are newly subject to the policy (see Figure 2). The remaining sectors each accounted for approximately $3 billion (6%) or less.
• There were 2,562 non-USG prime recipients of U.S. foreign assistance in FY 2024, most⁸ of which (2,111 or 82%) would be subject to the policy for the first time. This number should be considered a floor, since any sub-recipients of U.S. foreign aid would also be subject to the policy.
• Whereas most funding was provided to multilateral organizations, most recipients (62%, or 1,587) were foreign-based organizations. About a third (34%, or 860) were U.S.-based organizations. Multilateral organizations accounted for the remaining 4% (115) (see Figure 3).
• NGOs (foreign- and U.S.-based) accounted for the vast majority (93%, or 2,386) of recipients. NGOs include:
  • non-profits (more than half – 52% – of all 2,562 recipients, or 1,339),
  • private sector organizations (more than a third – 35% – of all recipients, or 905), and
  • educational institutions (6% of all recipients, or 142).
• Among the 2,386 NGO recipients, almost two-thirds (64%, or 1,526) were foreign NGOs, and the other third (36%, or 860) were U.S.-based NGOs.
• The sectors with the largest numbers of recipients in FY 2024 were program support⁹ (768), health (756), and economic development (516). The next largest sector was democracy, human rights, and governance (510), followed by humanitarian assistance (315) (see Figure 4).

This analysis uses FY 2024 foreign assistance obligation data, downloaded from ForeignAssistance.gov on November 20, 2025. ForeignAssistance.gov is the U.S. government’s centralized data portal for budgetary and financial data provided by more than 20 federal agencies that manage foreign assistance programs. Obligations are binding agreements that will result in outlays of funding, immediately or sometime in the future. The policy, when in place, is applied to funding that is obligated to recipients either as part of an existing award or as part of a new award. Data on funding amounts and recipients were analyzed by agency, sector, location, and type of entity. To the extent possible, COVID-19 emergency funding was excluded from this analysis, as it represented one-time funding for a particular event.

Recipients were categorized into the following groups (see table below) based on classifications already present in the ForeignAssistance.gov data as well as background research, where such classifications were not provided. Each recipient was reviewed, and the review sought to correct any mis-categorization in the original data and remove duplicates. “Other/Unknown” recipients were those that could not be easily identified as belonging to a particular recipient type/sub-type. Where it was not possible to identify a recipient as a single, implementing entity, they were excluded from analysis looking at the number of unique recipients.

Funding included in the analysis was based on the specifications in the final rules and includes Title III funding appropriated to the State Department and USAID (now administered by the State Department) as well as funding appropriated to four other accounts under Department of State, Foreign Operations, and Related Programs (SFOPs)/National Security, State Department, and Related Programs (NSRP) appropriations acts (specifically, “International Narcotics Control and Law Enforcement,” “Nonproliferation, Anti-Terrorism, Demining and Related Programs,” “Peacekeeping Operations,” and “International Organizations and Programs”), whether or not these data were listed as “Economic” or “Military” funding. The analysis excluded the funding in these accounts that was directed to U.S. departments or agencies as prime recipients, which totaled $2.8 billion in FY 2024, as well as funding directed to “Other/Unknown” recipients, which totaled $1.5 billion in FY 2024 (although to the extent that this funding is ultimately provided to a non-USG sub-recipient, it too would be subject to the policy). The U.S. government has also indicated that its intention is to apply the latest MCP expansion to additional non-military foreign assistance at other U.S. agencies and departments, which would also increase the amount of funding and number of organizations subject to the latest expansion.

The analysis also includes funding provided through contracts (not just grants and cooperative agreements) for two reasons: first, the rules indicate that further rule-making will be undertaken to add these policy restrictions to contracts; and second, it is not possible to disaggregate obligations by funding instrument in ForeignAssistance.gov data.

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.

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.

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.

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.

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 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.

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.

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%).

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 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.

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.

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.

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.

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.

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.