While the implications of the election on the future of abortion access have received extensive attention, the stakes are also high for the future directions of Medicaid, a program that seven in ten women have a connection to. Vice President Harris and former President Trump hold vastly different views on abortion and Medicaid, key issues affecting women’s health, particularly for women in their reproductive years and with lower incomes. With regard to Medicaid, the Biden-Harris Administration policy proposals have generally focused on efforts to “protect and strengthen Medicaid and the Affordable Care Act (ACA)”, as well as repealing the Hyde Amendment, which limits federal spending on abortion; in contrast, Former President Trump supported plans to repeal or weaken the ACA, cap and reduce Medicaid financing, and restrict Medicaid eligibility while he was president. In a recent column, KFF President and CEO Drew Altman pointed out that Medicaid is the program most likely to be in the crosshairs if Republicans take control this November is Medicaid.

Changes related to Medicaid could have major consequences for health coverage of women with low incomes as well as pregnancy, postpartum and other reproductive health care for women. Here are the top five things to know about women and Medicaid ahead of the election.

1. Medicaid is a major source of coverage for women with low incomes (and their children). Medicaid provides coverage to one in five non-elderly adult women, the largest source of coverage after employer coverage (Figure 1).  Medicaid covers 43 percent of non-elderly women with low incomes (income below 200% FPL) and over half (52%) of poor women (income below 100% FPL). Medicaid also covers four in ten children and eight in ten poor children..
   
2. Medicaid provides coverage to women across the lifespan, including women who are older and those with chronic disabilities. Medicaid provides coverage to women with low incomes who qualify because they meet one of the eligibility categories (pregnancy, parent, disability, or age 65+), or have income less than 138% of poverty through the ACA expansion pathway. Nearly two-thirds (64%) of adult women who are covered by Medicaid are of child-bearing age. Medicaid also covers over four in ten (44%) nonelderly women with a broad range of physical and mental disabilities, including physical impairments and severe mental illnesses. Medicaid finances over half (54%) of all long-term care spending, which is critical for many frail elderly women and women who qualify on the basis of disability. In 2021, 20% of women with Medicare were also enrolled in Medicaid. For these women, Medicaid helps to pay Medicare premiums, deductibles and cost-sharing as well as pay for services not typically covered by Medicare such as long-term care..
3. Medicaid is a key source of coverage for pregnant and postpartum women and births as well as access to family planning and preventive services. Medicaid covers over 4 in 10 births nationally and the majority of births in many states. Medicaid has also been used as a lever to help address disparities in access and outcomes in maternal and infant health. KFF research has found that the ACA’s Medicaid expansion promotes continuity of coverage in both the prenatal and postpartum periods. Furthermore, as a result of a provision in the American Rescue Plan Act of 2021, nearly all states now allow pregnancy-related coverage to continue through one year postpartum. Over half of the states have established programs that use Medicaid funds to cover the costs of family planning services for low-income women who remain uninsured and Medicaid accounts for 75% of all publicly funded family planning. Most states have limited scope Medicaid programs to pay for breast and cervical cancer treatment for certain low-income uninsured women..
   
4. Medicaid provides very limited access to abortion services. The federal Hyde Amendment prohibits federal spending on abortions, except when the pregnancy is a result of rape or incest, or when it jeopardizes the life of the pregnant person. However, states may use their own unmatched funds to pay for abortions for Medicaid enrollees in other circumstances and 19 states currently do so..
   
5. Medicaid has broad support and the majority of enrollees prefer to keep it as it is today. The public’s views of Medicaid are also largely positive. KFF public opinion polling shows Medicaid has broad support across political parties, with majorities of Democrats, independents, and Republicans expressing a favorable view of the program. In addition, the majority of the public and Medicaid enrollees prefer to keep Medicaid as it is today, with the federal government guaranteeing coverage for low-income people, setting standards for who states cover and what benefits people get, and matching state Medicaid spending as the number of people on the program goes up or down. Seven in ten women have a personal connection to Medicaid (including health insurance, pregnancy-related care, home health care, or nursing home care, coverage for a child, or to help pay for Medicare premiums for themselves, a family member or close friend). Eight in ten adult women (79%) have a favorable opinion of the program (Figure 5)..
6. 

Key Points

• Major outbreaks of mpox – the infectious disease previously called monkeypox – are ongoing in a number of African countries, in particular the Democratic Republic of the Congo (DRC). In addition, several mpox cases linked to the DRC outbreak have now been identified in some non-African countries, including Sweden and Thailand. Due to these circumstances, in mid-August 2024, the World Health Organization (WHO) and the Africa Centres for Disease Control and Prevention (Africa CDC) each declared mpox to be a public health emergency requiring a globally coordinated response.
• This is the second time mpox has been declared an international emergency, with the first spanning 2022-2023. The current mpox outbreak centered in the DRC is being driven by the “clade I” strain of the virus, with a clade Ia variant that is primarily affecting children and a more recently identified clade Ib variant that is spreading primarily via sexual contact among adults. The previous international emergency was driven by a “clade II” strain, and primarily affected adult gay and bisexual men. Currently, there is ongoing transmission of both clades affecting mostly different geographic areas.
• The U.S. government has provided technical and financial assistance for mpox response in DRC and elsewhere for years. Following the emergency declarations it has increased this support, including by delivering 50,000 doses of mpox vaccine to the DRC and 10,000 doses to Nigeria, as well as providing $10 million in mpox response-specific funding. On September 24, President Biden also pledged to donate up to 1 million more vaccine doses and an additional $500 million in funding to support mpox response across Africa.
• Since the emergency declarations, the Africa CDC, WHO, and governments of affected countries have accelerated efforts to respond to the situation by developing updated response plans, mobilizing more funds and attention from policymakers, and working to obtain more mpox vaccine doses. Still, the response faces a number of challenges including an uncertain path to delivering mpox vaccines at scale, lack of access to prevention tools, poor health infrastructure in many affected areas along with ongoing conflicts and instability, and high levels of distrust and misinformation in affected communities.
• No cases of clade I mpox have been identified in the U.S. as of September 26, 2024, and the CDC estimates the risk to the general public in the U.S. from the current outbreak in African countries is very low. However, clade II mpox infections continue to occur in the U.S. primarily among adult gay and bisexual men, though case numbers have declined since the previous mpox emergency in 2022-2023.

Introduction

Major outbreaks of mpox are again raising significant international concern. The DRC in particular has reported a large increase in cases driven by the “clade I” strain of the mpox virus, including a “clade Ia” variant that is primarily affecting children and a more recently identified “clade Ib variant” that is spreading primarily via sexual contact among adults. Clade I cases are also being reported in some other African nations, and several cases of the clade Ib variant have now been identified in non-African countries. At the same time, there continue to be mpox cases caused by “clade II” mpox, which was the variant that led to an earlier public health emergency in 2022-2023 in many different regions and countries around the world, including in the U.S. The recent circumstances led to two public health emergency declarations: the Africa Centres for Disease Control and Prevention (Africa CDC) declared mpox to be a “public health emergency of continental security” (PHECS) for Africa on August 13, 2024, and the WHO Director-General declared the mpox outbreaks a “public health emergency of international concern” (PHEIC) on August 14, 2024.

This explainer answers key questions about the international response to date, including the U.S. government’s role globally, and identifies issues and challenges that may affect the response going forward. It also discusses how the global emergency might affect the U.S. and the current status of mpox circulation within the U.S. It will be updated as needed.

Key Questions

What is mpox?

Mpox is a disease caused through infection with the mpox virus (MPXV). The first human case of mpox was identified in 1970, and since then, the virus has caused intermittent outbreaks. It is considered endemic in several Central, East, and West African countries, where infections have traditionally occurred through exposure to rodents or other animals carrying the virus. Human-to-human spread is also possible, primarily through close contact such as skin-to-skin contact and sexual or other contact with infected body fluids. Mpox can also pass from mother to fetus during pregnancy and during or after birth. Mpox infections can lead to symptoms such as fever, headaches, and body aches, and the development of a rash with lesions. Some infections can cause severe illness and even death, and there is a higher risk for severe outcomes in those with weaker immune systems such as people with HIV who are not virally suppressed and children. In areas with poor health care infrastructure and a lack of access to prevention tools, testing, treatment, and supportive care, mpox can be more difficult to identify, treat, and contain.

In recent years, more sustained human-to-human transmission and larger mpox outbreaks have been recorded from two genetic families of mpox virus (known as clade I and clade II mpox viruses; see Box 1). Most notably, in 2022, an outbreak of clade II mpox virus emerged from West Africa and spread globally, eventually affecting more than 100 countries and causing over 100,000 reported cases, including over 30,000 cases in the U.S. alone. That global outbreak was declared a PHEIC by WHO between July 2022 and May 2023 , and also declared a public health emergency in the U.S. in August 2022, marking the first time mpox had become a significant public health threat in non-endemic countries. Adult gay and bisexual men, especially men of color, made up the vast majority of cases during that outbreak in the U.S.

Strains of mpox virus (MPXV) from both clades have continued to circulate in largely geographically separate sets of endemic African countries, with clade II mpox infections primarily found in West African and Southern African countries and clade I infections found in Central African countries, the DRC in particular. In addition, clade II infections continue to be identified in many countries outside endemic regions, including in the U.S., primarily in gay and bisexual men, though the number of reported cases has declined significantly since the 2022 global outbreak.

Why has mpox again been declared a public health emergency this year?

WHO and Africa CDC issued the emergency declarations due to the recent rapid rise in case numbers and expanded geographic reach of mpox. Of primary concern has been mpox in the DRC. In 2023, the DRC reported more than 14,000 suspected cases (three times as many as in 2022) and over 500 deaths from mpox. In 2024, these trends have accelerated, and in only the first half of this year, the country has reported over 14,000 suspected cases across 23 different provinces, with over 450 deaths. Children have been heavily affected in the DRC outbreaks, with an estimated 70% of mpox cases and 85% of mpox deaths in the country since 2022 occurring in children under 15.

Moreover, the emergence and rapid spread of a new strain of the mpox virus (known as clade Ib; see Box 1) that “appears to be spreading mainly through sexual networks” was first identified in eastern DRC in 2023 has not only caused a growing number of cases in the DRC, it has been found in a number of other countries in the region and outside Africa with one case detected in Sweden and one in Thailand. There are concerns that clade Ib virus may be more readily transmissible (including via sexual contact) compared to clade Ia, which could be contributing to the increased numbers of cases and the cross-border spread of the disease.

What has been the global response to the current mpox emergency?

Alongside its PHEIC declaration on August 14, WHO released $1.45 million from its Contingency Fund for Emergencies to help scale up the response in affected countries. On August 26, WHO issued a Global Mpox Strategic Preparedness and Response Plan (SPRP) that outlined a set of global, regional, and country level response steps and needs to address the spread of clade Ib in eastern DRC and to control outbreaks of clades I and II in the DRC and other African countries. The plan emphasized the need for better mpox surveillance, strengthening clinical care for the disease, more global cooperation to increase vaccine access, implementation of strategic vaccination efforts in populations at highest risk, and public health communication efforts and community empowerment.

Along with its declaration on August 13, Africa CDC requested $20 million for immediate mpox response needs (and reported it had been granted $10.4 million) from the African Union, and initially requested an additional $16 million from WHO and other international partners for a continent-wide response. The Africa CDC and WHO also launched a joint plan, the Mpox Continental Preparedness and Response Plan for Africa, covering the September 2024 through February 2025 period identifying the following:

• 10 “pillars” for the continental response including coordination and leadership, case management, vaccination, and logistics and financing;
• roles and responsibilities for the primary international organizations involved in the response, including Africa CDC, WHO, Gavi, the Vaccine Alliance, and UNICEF;
• the need for approximately $600 million to address the outbreak on the continent during the plan period (with 55% to be allocated to the mpox response in 14 affected countries and to boost readiness in 15 other countries at risk and 45% to be allocated to operational and technical support through partners), calling on donor governments, philanthropic organizations, and the private sector to provide this funding. Recent pledges from the U.S. and other donors totalled

In addition, Africa CDC activated its Public Health Emergency Operations Centre (PHEOC), initiated negotiations with pharmaceutical manufacturers and others to obtain mpox vaccines for use in outbreak response on the continent (see Box 2 for more on mpox vaccines), began supporting laboratory testing capacity building for mpox, and deployed epidemiologists to affected areas, among other activities.

Are mpox vaccines available, and are they getting to affected countries quickly?

There are several vaccines that can be used to prevent mpox (see Box 2). Africa CDC and WHO consider vaccines to be a key prevention tool for the response, and the joint Africa CDC and WHO continental response plan calls for enough vaccine doses to vaccinate 10 million people in African countries from September 2024 through February 2025. However, there are a limited number of vaccine doses available other than those already stockpiled by high-income countries.

Some high-income countries have agreed to donate vaccine doses from their existing stockpiles in support of the global response. For example, the European Commission announced a donation of 175,000 doses to Africa CDC, and Japan agreed to donate up to 3.5 million doses for response in the DRC. The U.S. has pledged to provide 1 million doses for the response, and has already delivered 50,000 doses to the DRC and 10,000 doses to Nigeria (see more on the U.S. role in mpox response below). In addition, Bavarian Nordic, the company that manufactures one of the mpox vaccines, pledged to donate 40,000 of the doses it has on hand to the DRC and to ramp up production of more doses for use in African countries in the coming months. Taken together, donors have pledged to provide a total of over 5.4 million doses of mpox vaccine for this response, according to WHO.

UNICEF and Gavi are also assisting in the process of acquiring vaccine doses and implementing vaccination in affected areas. Gavi announced it would redirect $2.9 million in funding to support mpox vaccinations in the DRC, and also is talking with vaccine manufacturers to help purchase doses directly, using funds drawn from its First Response Fund. Gavi is also helping coordinate the delivery of donated vaccines to countries in need. UNICEF reports that it is providing vaccination supplies and logistics support, health worker trainings, transportation, storage, and vaccine administration in the country.

As of September 24, 2024, 250,000 doses – 200,000 doses from the European Commission and Bavarian Nordic, along with the 50,000 doses from the U.S. – have arrived in the DRC. However, this is just a small fraction of the over 3 million doses that health authorities say are needed in the country in the near term. The DRC government announced it expects mpox vaccinations to begin in the country in the first week of October.

In other nearby countries reporting recent clade I mpox cases (such as Burundi, Rwanda, and Uganda), there is little information so far about if mpox vaccines will be provided in-country and when vaccinations may begin.

What assistance has the U.S. provided to the DRC for mpox response?

The U.S. government has long provided support to help DRC address mpox. For example, CDC has supported mpox research and response efforts in country for decades. Over the last few years, U.S. support for mpox response has included efforts to build laboratory testing capacity in-country, conduct mpox vaccine research, and training health care workers.

With the growth in mpox cases in the DRC and the emergency declarations from Africa CDC and WHO, the U.S. government has announced a number of additional actions. This includes a U.S. commitment to provide over $55 million in emergency health assistance through USAID and the U.S. CDC for mpox response in DRC and other affected countries in Africa, including $10 million in additional funding announced in August specifically for clade I mpox response efforts. Also, the U.S. donated 10,000 doses of mpox vaccine to Nigeria in August and delivered 50,000 doses of mpox vaccine to the DRC in September, along with additional support for vaccine delivery.

On September 24, President Biden stated the U.S. would increase its support over the coming months, and expects to provide over $500 million in additional assistance for the mpox response in African countries as well as donate as many as 1 million mpox vaccines in support of the response.

Besides its mpox-specific support, the U.S. government has also long provided significant amounts of global health and humanitarian assistance to the country, and recently stated it would be expanding assistance for broad humanitarian efforts in the DRC.

What are key challenges in responding to the current mpox emergency?

Addressing the current mpox emergency in the DRC and other affected countries in Africa poses a number of challenges, including:

• Limited testing, surveillance, and epidemiological capacity. There is a lack of point of care testing and laboratory capacity in many affected areas, which means many suspected cases of mpox may be undiagnosed and suspected cases unconfirmed. This is particularly true in regard to genomic sequencing. This hampers epidemiological investigations and leaves many questions unanswered about the current state of mpox in the DRC and elsewhere. More testing and epidemiological information on modes of disease transmission, risk factors, and disease severity associated with the different MPXV clades, as well as outcomes of pregnancy in women infected with different MPXV clades, would help authorities target response efforts.
• Difficulties with obtaining and distributing mpox vaccines at scale. There is currently a limited global supply of mpox vaccines, with many of the existing doses found only in national stockpiles of high-income countries so the response relies in large part on donations. Also, there is a lack of formal authorization to use these vaccines in a number of the affected countries in Africa and little data on the effectiveness of these vaccines against clade I mpox or their effectiveness in children. A new, large-scale vaccination campaign to reach the populations at greatest risk for mpox is also a challenge.
• Stigma and overlapping risks of mpox and HIV infection. There are relatively high rates of HIV infection in some mpox-affected countries in Africa, which raises concerns about the potential overlap in risks between these infectious diseases. Unsuppressed HIV infection could raise the risk for mpox transmission, especially in the context of sexual contact, and for development of more severe outcomes from mpox infection. In addition, both infections can lead to stigma for those affected, making the response more challenging. Therefore, ensuring public health authorities plan to address HIV and mpox in a coordinated fashion will be important.
• Health systems and health care workforce. Lack of access to health care and a limited health care workforce increase risks from mpox for individuals and communities. Linking mpox cases to health care services as early as possible and ensuring the health care workforce is adequately trained and supplied to address mpox improves outcomes.
• Travel restrictions. To date, countries have not put into place harsh restrictions on travel to and from areas affected by this mpox emergency. However, if the outbreak worsens and spreads to more countries, there is the potential for countries to impose travel bans or other restrictions, as has occurred during past outbreaks. There is little evidence to support the effectiveness of such restrictions in interrupting international transmission of mpox.
• Competing priorities amid instability, conflict, and community distrust. Many of the affected countries – the DRC in particular – face multiple simultaneous humanitarian crises, health emergencies, and other urgent issues in addition to mpox. This makes focusing attention on and implementing a response to mpox more challenging, especially in the context of limited resources. For example, in some affected areas in the DRC, there is a history of instability and conflict and an ongoing lack of trust in authorities in many communities, which complicates response and risk communication efforts particularly those focused on reaching the most at-risk populations.

How might this latest outbreak affect people in the U.S.?

Although cases of mpox due to clade II infections continue to occur in the U.S. (see below), so far no cases of mpox due to clade I infections – the genetic family linked to the current DRC outbreak – have been identified in the U.S. The U.S. CDC estimates that the risk to the general public from the current mpox outbreak in African countries remains very low. The CDC also estimates there is a low to moderate risk from the current DRC-based clade I outbreak for U.S. gay, bisexual and other men who have sex with men (MSM) who have more than one sexual partner as well as for people who have sex with MSM, regardless of gender, particularly if there is a history of travel to any of the African countries affected in the current mpox emergency.

In light of the evolving mpox situation in parts of Africa and the potential risk of imported cases, CDC has issued a travel warning for the DRC and has issued several health alerts for U.S. clinicians, which provide guidance on prevention strategies and also suggest a “heightened index of suspicion” for mpox in patients recently arriving from affected areas in Africa who demonstrate signs and symptoms consistent with the disease.

Given the rise in anti-immigrant rhetoric and a history of charged debates about travelers entering the U.S. during health emergencies, there is the potential for mpox to become politicized this election year, especially if cases linked to the ongoing outbreaks in Africa are eventually identified in the U.S.

What is the status of ongoing mpox circulation in the U.S.?

As mentioned above, in 2022-2023, the U.S. had over 30,000 mpox cases during the global outbreak of clade II mpox, which had initially emerged from West African countries. While case numbers have declined in the U.S. since 2022, some clade II mpox cases continue to be identified, with CDC reporting 1,968 mpox (clade II) cases so far this year nationwide as of September 1, 2024. These cases have primarily occurred among adult gay, bisexual and other men who have sex with men (MSM) who have multiple sexual partners, especially men of color and with people with HIV being disproportionately impacted. According to CDC, during the peak of the epidemic in 2022 over 99% of mpox clade II cases in the U.S. occurred among men, and of those, 94% were among men who had sexual contact with other men.

The 2024 election is the first Presidential election since the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization, and abortion access and reproductive health more broadly, are front and center in this election (Figure 1). The two candidates, Vice President Kamala Harris (D) and former President Donald Trump (R) have widely different positions on reproductive health. Vice President Harris has been and is an outspoken leader and advocate for reproductive freedom, while former President Trump celebrates the overturning of Roe v Wade, which ended the constitutional right to abortion and allowed states to completely ban or severely restrict abortion access. The candidates’ Vice-Presidential running mates, Governor Tim Walz (D) and Senator JD Vance (R) also have divergent records on reproductive health issues. Governor Walz points to his support for Minnesota’s Protect Reproductive Freedom Act, which codified abortion rights in the state, as well as his family’s own experience with fertility care. Senator Vance has expressed support for a national abortion ban via the Comstock Act and voted against a Senate bill that would have established a national right to IVF, a position that his running mate, Donald Trump, has said he supports.

While abortion is the most prominent health care campaign issue, the election could also have large implications for contraceptive care and maternal health. This brief summarizes the positions, records, and potential priorities of the two major party candidates for the 2024 Presidential election on three major issues in women’s health policy – abortion, contraception, and maternal health. The information presented is derived from the candidates’ records from their time as elected officials, their proposals or statements, and the Democratic and Republican party platforms. We have also included discussion of proposals from the Heritage Foundation’s Project 2025. While former President Trump has distanced himself from this proposal, its authors are influential in Republican circles and include several individuals who served in the Trump Administration. A separate side-by-side from KFF compares the candidates’ positions across a broad range of health care issues.

Abortion

Abortion access is one of the most prominent issues in the 2024 election, and the candidates have widely divergent records and positions. Vice President Harris has been an outspoken advocate for reproductive freedom and has endorsed the restoration of the prior federal standard under Roe v. Wade, which would guarantee a right to abortion until the point of fetal viability. In contrast, Trump expresses his support for letting states set their own abortion policy, including banning abortion, as allowed under the Dobbs Supreme Court ruling.

Vice President Harris has been vocal in her disagreement with the Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade and allowed states to set their own policy on abortion legality. In stark contrast, Trump has repeatedly taken credit for the overturning of Roe and giving states decision-making authority on abortion because he appointed three conservative justices to the Supreme Court with the explicit goal of overturning Roe. Since the Dobbs ruling, 14 states have banned abortion with very few exceptions and several other states have limited abortion availability to very early in pregnancy.

Abortion Access

Vice President Harris has been the leading voice for the Biden/Harris Administration on reproductive health and has said she supports restoring the protections of Roe v. Wade and eliminating the filibuster to do so. In the wake of the Dobbs ruling, the Biden-Harris administration has tried to limit the impact of the bans through executive actions as well as in the courts. This includes reiterating federal protections for abortion care under EMTALA in cases of pregnancy-related emergencies, reinforcing requirements for pharmacies to fulfill their obligation to provide access to reproductive health pharmaceuticals, enforcement of non-discrimination policies for health care providers, promulgating policies to strengthen data privacy to protect those seeking reproductive health care, and defending the FDA decision to approve mifepristone (one of the drugs used in the medication abortion regimen) and changes in how the drug can be dispensed. Vice President Harris opposes the Hyde Amendment, which limits federal spending on abortions to cases of rape, incest, or life of the pregnant person.

In 2016, Trump ran on the promise that he would appoint Supreme Court judges that would overturn Roe v. Wade, a promise he kept. Most recently, he has stated that he believes that abortion regulation should be left up to states and tweeted that he would veto a federal ban. At times earlier in the campaign he has suggested that he would support some type of federal standard, such as 15 or 16 weeks gestation, that would apply in all states. He has said that he believes in exceptions for cases of rape, incest, and life of the mother. Despite stating that he believes that abortion bans or limits at 6 weeks are “too early,” he also said he will vote against the ballot initiative that would expand abortion legality in Florida, where he resides (currently limited to six weeks of pregnancy). In terms of penalties for violation of bans or gestational limits, he has said that they should be also decided by states, even leaving open the possibility of allowing states to prosecute people in states with bans if they obtain abortions.

Trump has repeatedly stated that Democrats support abortion up to and after birth, which is false. There are no abortions at birth or after. During the 2016 campaign, he pledged to make the Hyde Amendment abortion funding ban a permanent law.

Medication Abortion

Medication abortion pills account for the majority of abortions in the U.S. The Biden-Harris Administration has implemented policies that expand access to medication abortion, particularly via telehealth, and has been fighting lawsuits brought by anti-choice clinicians and policymakers to further restrict abortion access. Former President Trump’s statements about medication abortion have been inconsistent, at times suggesting he would not block their availability and at other times suggesting the opposite. His support for leaving abortion policy to the states allows states to prohibit access to all abortions, including medication abortion. Project 2025—the detailed conservative policy treatise that was spearheaded by many former Trump Administration leaders—is clear in its opposition to the FDA’s approval of mifepristone and endorses the Comstock Act, which would effectively prohibit the mailing and distribution of abortion pills.

The Comstock Act is an existing 1873 anti-vice law banning the mailing of obscene matter and articles used to produce abortion. The Biden-Harris Administration’s Department of Justice maintains that the Comstock Act should not be interpreted literally and therefore has not enforced it. Based on over a century of Federal Court rulings, they determined the Comstock Act only applies when the sender intends for the material or drug to be used for an illegal abortion, and there are legal uses of abortion drugs in every state and no way to determine the intent of the sender. However, that would not preclude an Administration that is hostile to abortion from doing so. Former President Trump has not articulated his stance on enforcement of the Comstock Act, but some Republican leaders, including his running mate Senator Vance, have called for enforcement of the law and a halt on the mailing of all abortion medications and supplies within the country (which would be a de facto national ban) and even limiting access in states that currently allow abortion without restrictions.

Pregnancy-Related Emergency Care

Health exceptions to abortion bans is an issue that Vice President Harris has spoken about extensively. In addition to reiterating the federal EMTALA requirements for hospitals to provide health-stabilizing emergency care that includes abortion in cases of pregnancy-related emergencies, the Biden-Harris administration defended their policy in a case that reached the Supreme Court. This challenge was spearheaded by Republican-led states that ban emergency abortion care, even when it is the standard of care to preserve or stabilize health. President Trump says he believes in exceptions for “life of the mother.” Project 2025 authors say that emergency abortion denials are not a problem and call for the reversal of the Biden-Harris Administration’s EMTALA guidance and withdrawal of lawsuits challenging state abortion bans without health exceptions.

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Contraception

Access to contraception has emerged as another health care issue in this year’s election where Vice President Harris and former President Trump have different records. Vice President Harris’ call for reproductive freedom includes access to contraception, and her support on this issue extends back to her time before she became Vice President. Since the Dobbs decision, the Biden-Harris Administration issued executive orders reiterating support for contraception and directing various federal agencies and regulators to assure that access to the full range of contraceptive services and supplies is safeguarded. Trump’s Administration issued multiple regulations that placed restrictions on the availability of funding for contraception. During his campaign, he initially expressed that states could restrict access to contraceptives, but shortly afterwards, also said that he would not support this.

Right to Contraceptives

Vice President Harris is a strong supporter of contraceptive care, including coverage of over-the-counter methods, encouraging broader access under Medicare and at colleges and universities, and for the proposed federal Right to Contraception Act, which is pending in Congress. Although Trump has not spoken extensively about contraception during this campaign, the Republican party platform states support for “access to birth control;” however, there is no detail on the policies that they would implement to promote access. The majority of the Republican members of Congress (including Senator Vance) either opposed or abstained from voting on the Right to Contraception Act. Project 2025 characterizes some emergency contraception pills—a contraceptive that prevents pregnancy after sex by preventing or delaying ovulation, as a “potential abortifacient.”

Title X Federal Family Planning Program

While in office, Trump’s Administration rewrote the rules governing the federal Title X program, the federal family planning program that supports contraceptive access for people with lower incomes. Title X funds have never been used to pay for abortion services, but Trump’s Administration rewrote the regulations to disqualify family planning clinics from participating in the program if they also offered abortion services (with separate funding); additionally, they prohibited participating clinics from offering referrals to abortion services at other clinics to pregnant patients seeking abortion information. These changes resulted in a reduction of about 1,300 of the 4,000 sites participating in the network of clinics receiving federal support from the Title X program. His Administration also provided federal family planning funding through Title X funds to clinics that did not provide contraceptive methods, which had been a requirement of the program until that time. The Biden-Harris Administration reversed the Trump Administration changes to the program. Project 2025 calls for the restoration of the Trump-era rules and focusing the program on fertility-awareness based methods (FABM).

Medicaid and Family Planning

For decades, the Medicaid program has required coverage for family planning services, including contraceptives. The Biden–Harris Administration has reiterated support for this policy as well as the program’s “free choice of provider” policy which commits to inclusion of all qualified providers (including Planned Parenthood) that offer both contraception and abortion services, although federal Medicaid funds are not used for abortion care. Former President Trump allowed federal Medicaid funds to be used in a Texas Medicaid program that excluded Planned Parenthood and did not cover the full range of contraceptives, excluding emergency contraception. Eliminating Planned Parenthood from Medicaid provider networks has long been a priority of some Republican lawmakers and conservative organizations and is reiterated by Project 2025.

Contraceptive Coverage and the ACA

Private insurance coverage for contraceptives and other evidence-based preventive services such as cancer screenings and prenatal care is required under the ACA and has been championed and expanded by the Biden-Harris Administration. While President, Trump issued regulations that expanded facilitated employer claims to an exemption from the contraceptive coverage requirement, allowing employers with religious or moral objections to completely exclude contraceptives from their employee health plans.

The outcome of a pending federal lawsuit, Braidwood Management Inc v Becerra, which specifically challenges the ACA preventive services requirements, could put contraceptive coverage at risk. The Biden-Harris Administration is defending the ACA requirement and fighting the case. Former President Trump has not publicly voiced an opinion on the case, but Project 2025 calls for the federal government to issue new requirements for contraceptives and other women’s preventive services because of the pending case.

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Maternal Health

In recent years, there has been increased awareness and attention to the poor state of maternal health in the U.S., particularly stark racial and ethnic disparities in mortality and morbidity, as well as limited access and coverage for fertility assistance, particularly in vitro fertilization (IVF), under private insurance and Medicaid. While in the Senate and as Vice President, Harris has been a champion on improving maternal health, with a particular focus on eliminating persistent racial and ethnic disparities. Recently, has called for insurance coverage of IVF.

Equity, Quality, and Access to Care

Vice President Harris has a history of advocating for improvements in maternal health and care. As Senator, she sponsored the MOMNIBUS, a package of bills aimed at improving quality of and access to maternity care. After becoming Vice President, the American Rescue Plan Act (ARPA) of 2021, which the Administration supported, allowed states to extend postpartum coverage under Medicaid from 60 days to 12 months. Since it took effect, nearly all states have adopted the extension.

The Biden-Harris Administration has also taken other actions, including the launch of a maternal mental health hotline and a new Medicaid payment model for better coordinated maternity homes. Their Maternal Health Blueprint presents future priorities, such as coverage for a broader range of services, improving data collection, diversifying the maternity workforce (including with midwives and doulas), and improving treatment of pregnant people, particularly communities of color.

Trump also issued a maternal health plan near the end of his term that called for action on many of the same issues, including more research and technological investments in maternal health. The former President signed federal legislation that provided funding for maternal mortality review committees. The Project 2025 document supports broader access to doulas, as long as no federal funds support training related to abortion care.

Fertility Assistance and IVF

In February 2024, the Alabama Supreme Court ruled that embryos created through in vitro fertilization (IVF) are “unborn children” under the state’s law. Since the state court’s ruling, both Vice President Harris and former President Trump have expressed their support for IVF care. Trump has also said that if elected, his administration would provide access to full coverage of IVF services by requiring insurance companies or the government to pay, but he has not provided any details on how this would be funded or operationalized.

Both party platforms express support for IVF, however the Republican platform also invokes the 14^th Amendment, which can be used to promote fetal personhood policies that could threaten and criminalize IVF care. Additionally, the Project 2025 authors refer to embryos as “aborted children” and oppose research using embryonic stem cells (which can be derived from the IVF process). Senators in both parties introduced federal legislation related to IVF. The Democratic-sponsored proposal would have established a federal right to IVF as well as other fertility assistance services, while the Republican-backed bill would have prohibited states from banning IVF care. Both bills failed to pass.

Paid Leave

Despite strong public support, the U.S. is one of the few industrialized nations that does not have national requirements for paid family leave for most workers. Vice President Harris supports guaranteeing 12 weeks of paid leave for new parents, caregivers, cases of domestic violence, or military deployment. The Republican Party platform does not address paid leave. During former President Trump’s time in office, he signed the 2020 National Defense Authorization Act, which provided 12 weeks paid parental leave to federal employees for the birth or arrival of a child.

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Nearly half (47%) of metropolitan areas across the country had only one or two hospitals or health systems providing general inpatient hospital care in 2022, a new KFF analysis finds.The analysis examines the extent of competition among hospitals amid a wave of hospital consolidation that has drawn the attention of state and federal regulators. About one in five (19%) metropolitan statistical areas have only one hospital or health system providing hospital care, and more than a quarter (27%) are controlled by two hospitals or systems.  In a large majority of metro areas (82%), one or two hospitals or health systems were responsible for at least three quarters of all inpatient hospital discharges in their area, thereby meeting the definition for highly concentrated markets based on current federal antitrust guidelines.

The number of hospitals or health systems in a metro area tends to increase with the population of the region, with a large majority of smallest metro areas (less than 200,000 residents) having only one or two hospitals or health systems providing inpatient hospital care, while nearly all of the largest areas (at least one million people) having at least four hospitals or health systems.Other findings include:

• Nearly all (97%) metropolitan areas had highly concentrated markets for inpatient hospital care in 2022 based on the Herfindahl-Hirschman Index, which takes into account the market shares of the participants in a given market. The Federal Trade Commission and Department of Justice include this measure of competitiveness in their current guidelines for evaluating mergers between hospitals or health systems
• Two thirds (67%) of hospitals nationwide were affiliated with health systems in 2022, up from 56% in 2010. The rise in affiliated hospitals affected both rural and nonrural areas, though nearly half (48%) of hospitals in rural areas remain unaffiliated with larger health systems.

With open enrollment less than a month away, a new KFF analysis suggests that the vast majority of the nation’s 67 million Medicare beneficiaries will not shop around among the coverage options for 2025 or switch plans. It’s a decision that could have a significant impact on enrollees’ coverage and costs.

The analysis of federal data shows that nearly 7 in 10 Medicare beneficiaries (69%) did not  compare their Medicare coverage with other Medicare options during the program’s annual open enrollment period for coverage in 2022. Enrollees in traditional Medicare were slightly more likely to skip shopping around than those in Medicare Advantage plans (73% vs. 65%). 

The Centers for Medicare & Medicaid Services recommends that beneficiaries compare their options because coverage and costs can vary widely, especially among Medicare Advantage plans that now enroll more than half of all eligible Medicare beneficiaries. From one year to the next, Medicare Advantage plans can change their premiums, cost-sharing requirements, provider networks, or prior authorization requirements. For beneficiaries who simply stay put in their existing plan, such changes could lead to unexpected, avoidable costs and disruptions in care.The new analysis examined the subset of Medicare beneficiaries enrolled in a Medicare Advantage plan, finding that 43% of enrollees did not review their own plan’s coverage during the open enrollment period to see whether there would be changes for 2022 to their monthly premiums, deductibles, co-payments, or other out-of-pocket expenses. The share not reviewing their own plan for changes in costs was even higher among enrollees in fair or poor self-assessed health (50%), enrollees who are Black (50%) or Hispanic (65%), and enrollees ages 85 and older (57%).Similarly, 44% of Medicare Advantage enrollees did not review their current plan for changes to the kinds of treatments, drugs, and services offered for 2022.New changes for 2025 include prescription drug provisions in the Inflation Reduction Act of 2022 that will lower out-of-pocket costs for all Part D enrollees, including a new $2,000 cap on out-of-pocket spending starting in January. In response, Part D plan sponsors may make changes to plan premiums, formularies, and cost sharing — making it especially important for beneficiaries to compare their prescription drug options during open enrollment.

In the past, many have not. The analysis shows that 82% of enrollees in Medicare Advantage prescription drug plans and 69% of enrollees in stand-alone Part D prescription drug plan did not compare their plan’s drug coverage with drug coverage offered by other plans in their area for 2022.

More broadly, relatively few beneficiaries use Medicare’s official information resources. The analysis finds that just a quarter (26%) reported calling the toll-free 1-800-Medicare helpline, four in 10 (42%) reported visiting the Medicare website, and slightly more than half (54%) reported reading some or parts of the Medicare & You handbook.

Also released today is KFF’s What to Know about the Medicare Open Enrollment Period and Medicare Coverage Options. It provides information about the kinds of changes Medicare beneficiaries can make to their coverage, how supplemental coverage can factor into decisions, how Medicare supports for low-income people relates to coverage decisions, how the features of traditional Medicare compare to Medicare Advantage, and how prescription drug coverage plans vary.

The Medicare open enrollment period runs from October 15 through December 7.

With immigration and border security getting attention heading into November’s elections, a large majority of the public reports hearing false claims about immigrants from candidates or elected officials, and many immigrants say the rhetoric is negatively affecting how they are treated, a new KFF Health Misinformation Tracking Poll finds.

Fielded before the Sept. 10 debate between former President Trump and Vice President Harris, the poll tested the public’s awareness of, and belief in, several statements about immigrants, both false and true. A companion survey of immigrants examines their views and experiences during the campaign.

Most of the public say they have heard candidates or officials make the false claims that “immigrants are causing an increase in violent crime” (80%) and that “immigrants are taking jobs and causing an increase in unemployment for people born in the U.S.” (74%).

About one in five people wrongly say that each of those two false claims are “definitely true,” with similar shares saying they are “definitely false.” In each case, a majority falls somewhere in between, describing the claims as only “probably” true or false.

For many immigrants, campaign rhetoric can have tangible effects. Nearly four in ten (36%) immigrants – including almost half (45%) of Asian immigrants – say that the way former President Trump talks about immigrants has negatively affected the way they are treated. Few (7%) say the same about Vice President Harris’ rhetoric, while about one in five (21%), including three in ten (30%) Asian immigrants, say that her rhetoric has had a positive effect.

When asked about the potential outcome of the election for immigrants, a narrow majority (55%) of immigrants say they would be better off if Vice President Harris wins, roughly three times the share that say that they would be better off if former President Trump wins (19%). A quarter (26%) say that who the president would not make a difference in the lives of U.S. immigrants.

“Everyone is quick to point to social media as the source of misinformation, and it often is, but it’s candidates who are amplifying misinformation about immigrants. Our poll shows that they’re harming immigrants in the process,” said KFF President and CEO Drew Altman, who also wrote a new column on the issue following comments by former President Trump and Sen. J.D. Vance about Haitian immigrants in Springfield Ohio.  

The poll of the public at large also reveals sharp differences among partisans in their likelihood to endorse those false claims.

Specifically, about four in ten (45%) Republicans say it is “definitely true” that immigrants are causing an increase in violent crime in the U.S., while a similar share (39%) of Democrats say this claim is “definitely false.” And about three in ten (31%) Republicans say the false claim about immigrants causing an increase in unemployment for U.S.-born people is “definitely true,” while nearly half (46%) of Democrats say it is “definitely false.”

Many People, Including Immigrants, Are Confused about Eligibility for Federal Health Benefits

The poll also gauges the public’s – and immigrants’ – understanding about immigrants’ eligibility for government benefits programs amid former President Trump’s false claims during the campaign that immigrants drain federal benefit programs and receive free government health care.

Half of the general public (51%) and immigrants (49%) do not realize that undocumented immigrants are not eligible for health insurance programs paid for by the federal government, either saying either that they aren’t sure or wrongly saying that they are eligible.

Similarly, half or more of the public and immigrants do not understand that most immigrants are not eligible for Social Security, Medicare, or Medicaid benefits as soon as they arrive in the U.S., saying either that they aren’t sure or wrongly saying that they are eligible immediately.

Under longstanding federal policy, most lawfully present immigrants, with some exceptions, are generally ineligible to enroll in federal benefit programs like Medicaid until they have resided in the U.S. for at least five years. Undocumented immigrants are ineligible for federally funded health insurance programs.

A related new KFF report explains these rules as well as other key facts about immigrants’ use of health care and its costs.

Designed and analyzed by public opinion researchers at KFF. The KFF Health Misinformation Tracking Poll was conducted August 26-Sept. 4, 2024, online and by telephone among a nationally representative sample of 1,312 U.S. adults in English and Spanish. Findings for immigrant adults are based on a separate nationally representative survey of 543 immigrant adults (people living in the U.S. who were born outside the U.S. and its territories). The survey of immigrants was conducted August 19-September 17, 2024 online and by telephone in English, Chinese, Spanish, Korean, and Vietnamese. The margin of sampling error is plus or minus 4 percentage points for total U.S. adults and 6 percentage points for immigrant adults. For results based on other subgroups, the margin of sampling error may be higher.

Immigrant adults are a diverse population who make up 16% of adults in the United States and play a significant role in the nation’s workforce and communities. Leading up to the 2024 election, there has been an increase in anti-immigrant rhetoric and immigration has been a central talking point for candidates. The Trump campaign has repeatedly described immigrants as a source of crime, a burden for taxpayers, and a drain on government programs like Medicare and Social Security. The Harris campaign has also focused on immigration, emphasizing her tough on crime stance as a former attorney general of a border state, while also highlighting her family’s immigrant roots. Some states have also taken restrictive actions focused on immigrants, including requiring hospitals to collect patient immigration status.

Amid this rhetoric and these recent state actions, data on immigrants’ health care use and costs as well as their contributions to the economy and workforce, including in the health care sector, can be informative. This brief provides key data on these topics drawing on KFF analysis across a range of data sources, including the KFF/LA Times Survey of Immigrants, the largest nationally representative survey of immigrants conducted to date, and other research.

Immigrants are not more likely than U.S.-born citizens to report using government assistance for food, housing, or health care, and undocumented immigrants remain ineligible for federally funded assistance.

The 2023 KFF/LA Times Survey of Immigrants shows that, despite having lower household incomes and facing financial challenges, immigrant adults are no more likely than U.S.-born adults to say that they or someone living with them received government assistance with food, housing, or health care in the past year. Overall, about a quarter (28%) of both immigrant adults and U.S.-born citizen adults say they received this type of assistance in the past 12 months (Figure 1).

Lawfully present immigrants face eligibility restrictions for federal programs, including Medicaid and the Children’s Health Insurance Program (CHIP). In general, lawfully present immigrants must have a “qualified status” to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll even if they meet other eligibility requirements. Some lawfully present immigrants, such as refugees and asylees, are exempt from the five-year waiting period. States can also expand coverage to lawfully residing immigrant pregnant people and children without a five year wait. Lawfully present immigrants can purchase Affordable Care Act (ACA) Marketplace coverage and receive tax credits to offset the cost of that coverage without a five-year wait. Lawfully present immigrants can also qualify for Medicare but must have sufficient work history. If they do not have this work history, they can purchase Medicare Part A after residing legally in the U.S. for five years continuously.

Undocumented immigrants are not eligible to enroll in federally funded coverage including Medicaid, CHIP, or Medicare, or to purchase coverage through the ACA Marketplaces. Medicaid payments for emergency services may be made to hospitals or other providers on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. Emergency conditions include those that place an individuals’ health in serious jeopardy or cause serious bodily impairment or dysfunction, although states have discretion to determine what services can be reimbursed through Emergency Medicaid.

Some states have established fully state-funded programs to provide coverage to immigrants regardless of immigration status, although they vary in eligibility and scope of benefits provided. Research suggests that expanding health coverage for immigrants can reduce uninsurance rates, increase health care use, lower costs, and improve health outcomes.

Immigrants, particularly those who are undocumented, use less health care, including emergency room care, than people born in the U.S.

Overall, research shows that immigrants, including lawfully present and undocumented immigrants, use less health care than U.S.-born citizens. Moreover, the KFF/LA Times Survey of Immigrants shows that among immigrant adults, likely undocumented immigrants are less likely than lawfully present immigrants and naturalized citizens to report seeking or receiving care in the U.S. or having a health care visit in the past year. About six in ten (63%) likely undocumented immigrant adults report a health care visit in the past year compared with 74% of lawfully present immigrant adults and 82% of naturalized citizen adults.

Lower use of health care among immigrants likely reflects a combination of them being younger and healthier than their U.S.-born counterparts as well as them facing increased barriers to care, including language access challenges, confusion, and immigration-related fears. Prior KFF analysis found that Trump-era policies amplified these fears and contributed to greater reluctance to access care.

Immigrants have lower health care costs than U.S.- born people.

Reflecting their lower use of health care, immigrants have lower health care expenditures than their U.S.-born counterparts. KFF analysis of 2021 medical expenditure data shows that, on average, annual per capita health care expenditures for immigrants are about two-thirds those of U.S.-born citizens ($4,875 vs. $7,277) (Figure 3). This reflects lower spending for most types of health care, including office-based visits, prescription drugs, inpatient care, outpatient care, and dental care. These findings are consistent with other research which shows that immigrants’ overall health expenditures are one-half to two-thirds of those of U.S.-born individuals, regardless of status, and that per capita expenditures from private and public insurance sources are lower for immigrants, particularly for undocumented immigrants. For example, one study found that undocumented immigrants are more likely to be uninsured and have significantly lower health care expenditures than U.S.-born individuals per year, and that despite differences in the likelihood of being uninsured, there are no significant differences in rates of uncompensated care between undocumented immigrants and U.S.-born individuals.

Immigrants contribute to the economy through their role in the workforce and tax payments, with research showing that they help subsidize health care for U.S.- born people and stabilize Medicare and Social Security.

Immigrants support the nation’s workforce by filling unmet labor market needs, and research suggests that they do not take jobs away from U.S.-born people. They play a disproportionate role filling jobs in essential industries such as construction and agriculture that are at increased risk of adverse health outcomes and injuries, including climate-related health hazards. In addition, immigrants as well as the adult children of immigrants play outsized roles in the health care workforce as physicians, surgeons, nurses, and long-term care workers (Figure 4). As health care workforce shortages are projected to continue and the U.S. 65 and older population grows, immigrants could help mitigate these shortages.

Analysis shows that undocumented immigrants contribute billions in federal, state, and local taxes each year. It is estimated that more than a third of their tax dollars are payroll taxes that fund programs they cannot access, including Social Security, Medicare, and the federal share of unemployment insurance. Research further finds that immigrants pay more into the health care system through taxes and health insurance premiums than they utilize, helping to subsidize health care for U.S.-born citizens. Earlier research found that without the contributions undocumented immigrants make to the Medicare Trust Fund, it would reach insolvency earlier, and that undocumented immigrants result in a net positive effect on the financial status of Social Security.