Nearly half (46%) of the public says that they expect the new tax and budget law signed by President Trump earlier this month to generally hurt them and their families, nearly twice the share (26%) who say it will generally help, a new KFF Health Tracking Poll finds. Among people who rely on Medicaid for their health coverage, two-thirds (65%) say it will hurt their families compared to one in five (18%) who say it will help.

The law combines tax cuts with spending reductions, including cuts and changes to Medicaid and the Affordable Care Act that are expected to leave millions more people without health insurance. Among people with household incomes under $40,000 annually, most (56%) say that the law will hurt them.

Perceptions of how the law will impact people’s families varies among partisans. Most Democrats (72%) and just over half of independents (53%) say it will mostly hurt them and their families, while just over half of Republicans (54%) say it will help. Those who identify as supporters of President Trump’s “Make America Great Again” movement are more than five times more likely to say the law will help their families (61%) than hurt (9%).

The law itself remains largely unpopular, with many more people holding unfavorable views (63%) than favorable ones (36%).

The split is unchanged from June before the legislation dubbed the “big beautiful bill” by President Trump became law, though the new poll shows a sharper partisan divide, with Republicans more likely to view the law favorably and Democrats more likely to view it unfavorably.

Two-thirds (68%) of the public now say that they’ve heard “a lot” or “some” about the legislation, up from half who said the same in June.

The poll also examines what people are seeing about the legislation on social media. Most (73%), including similar shares of partisans, say they saw information about the bill on social media in the past month.

Among those who saw information about the legislation on social media, about half (47%) say most of the content they saw was in opposition to the legislation, while about one in ten (11%) say it was mostly in support. The others (41%) say they saw a mix of both.

Designed and analyzed by public opinion researchers at KFF, this survey was conducted July 8-14, 2025, online and by telephone among a nationally representative sample of 1,283 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

Since the Supreme Court overturned Roe v. Wade in June 2022, states have been able to set policy that defines abortion access across this nation. In the past three years, voters in 10 states have passed constitutional amendments to protect abortion rights. These amendments, however, do not automatically invalidate the states’ laws restricting abortion such as waiting periods, coverage bans, and ultrasound requirements. The restrictions need to be challenged in court before they can be invalidated. This process can take years, and in states with new constitutional protections, people seeking abortion care may still face access restrictions while the litigation proceeds. Additionally, in some instances, after courts have blocked restrictions, conservative state legislatures have passed laws enacting very similar restrictions, lengthening the process to block these laws, since advocates have to challenge multiple state laws or amend already-existing challenges to block the newly passed laws. This policy watch provides an update on the status of abortion restrictions in states that passed a constitutional amendment protecting abortion, or where a state court previously interpreted the state constitution as protecting abortion access.

Status of Litigation Based on Recent Constitutional Amendments

In four states with recently passed constitutional amendments protecting the right to abortion or a broader right to reproductive freedom — Arizona, Michigan, Missouri, and Ohio – advocates have filed lawsuits seeking to block abortion restrictions, alleging that these restrictions violate the newly passed constitutional amendments. These lawsuits test the reach of these constitutional amendments beyond pre-viability gestational limits. In Montana, another state that recently passed a constitutional amendment, abortion providers are also challenging prior abortion restrictions, but because this challenge was filed before the state’s constitutional amendment passed, they are relying on previous state supreme court precedent to make their arguments. Advocates in Alaska and Kansas, where there is no specific constitutional amendment protecting abortion, have challenged restrictions based on state supreme court cases finding abortion is protected in the state constitution.

Whether or not the restrictions that are being challenged will be permanently blocked depends on how each respective state’s supreme court interprets the state constitution’s right to abortion. The language of the constitutional amendments varies and some might provide greater protections than others (Table 9). States that rely on state supreme court precedent protecting a right to abortion—as opposed to a constitutional amendment explicitly protecting this right—may provide protections today, but future courts may overturn that precedent, much like the U.S. Supreme Court did with Roe v. Wade.

The following section provides an overview of the status of legal challenges to abortion restrictions in states with recently passed constitutional amendments or litigation that has found that the state constitution protects abortion rights.

Arizona

The Arizona constitutional amendment – passed in November 2024 – protects a fundamental right to abortion and forbids the state from enacting, adopting, or enforcing any law that “denies, restricts or interferes with that right before fetal viability unless justified by a compelling state interest that is achieved by the least restrictive means.” Currently, the gestational limit in the state is fetal viability. However, there are other restrictions that are still in effect.

Abortion rights advocates in Arizona filed a lawsuit in May 2025 challenging the in-person counseling requirement, 24-hour waiting period, ultrasound requirement, and ban on the use of telehealth for abortion care. The state court where this challenge was filed is yet to issue a ruling.

Michigan

In November 2022, voters passed a constitutional amendment in Michigan that protects a fundamental right to reproductive freedom, the right to make decisions regarding pregnancy, including the right to abortion, among others. It states that “[a]n individual’s right to reproductive freedom shall not be denied, burdened, nor infringed upon unless justified by a compelling state interest achieved by the least restrictive means.”

The state has no gestational limit on abortion, however, a state funding ban on abortion funding for Medicaid enrollees and a parental consent requirement are still in effect.

In two separate lawsuits, advocates in Michigan are challenging the exclusion of abortion coverage from the state’s Medicaid program and laws requiring a 24-hour waiting period and limiting abortion provision to physicians. A trial court recently ruled that the latter two requirements are unconstitutional and blocked them permanently. However, the state’s supreme court is yet to rule on these restrictions.

Missouri

In November 2024, voters in Missouri passed a constitutional amendment protecting a fundamental right to reproductive freedom, including the right to make decisions about abortion care. The amendment states that this right “shall not be denied, interfered with, delayed, or otherwise restricted unless the Government demonstrates that such action is justified by a compelling governmental interest achieved by the least restrictive means. Any denial, interference, delay, or restriction of the right to reproductive freedom shall be presumed invalid.” Currently, the gestational limit in the state is fetal viability, but other restrictions are still in effect.

Several clinics in Missouri filed a lawsuit alleging that the state’s pre-viability bans as well as many restrictions violate the state’s newly granted constitutional right to reproductive freedom. In December 2024, a Missouri state trial court sided with the clinics, and blocked the state’s pre-viability abortion bans, as well as many of the restrictions, while the litigation continues. However, in late May 2025, the Missouri Supreme Court lifted the preliminary injunction for the restrictions, and ordered the trial court to use a more strenuous test to determine if the plaintiffs meet the bar for a preliminary injunction. When restrictions went back into effect, clinics stopped providing abortion care, even though the total ban was not in effect. The case went back before the trial court, where the judge reviewed the request for a preliminary injunction using the standard set forth by the state supreme court and in response issued an order on July 3, 2025 blocking once again the state’s pre-viability ban and some restrictions, including the 72-hour waiting period. The state has appealed this order to the Missouri Supreme Court.

Ohio

The Ohio constitution was amended by voter initiative in November 2023 protecting the right to make and carry out reproductive decisions, including decisions about abortion care. Per the amendment, “[t]he State shall not, directly or indirectly, burden, penalize, prohibit, interfere with, or discriminate against… the exercise of this right, unless the State demonstrates that it is using the least restrictive means to advance the individual’s health in accordance with widely accepted and evidence-based standards of care.”

Currently, the gestational limit in the state is 22 weeks LMP (last menstrual period), however, are other restrictions are still in effect or temporarily blocked.

In two different lawsuits, abortion providers in Ohio challenged the 24-hour waiting period, the in-person counseling appointment, the telehealth abortion ban, and a law that limits the provision of abortion care to physicians. Abortion providers used the state’s constitutional amendment as the basis for these challenges. In both of these lawsuits, the trial courts have temporarily blocked the challenged restrictions while litigation proceeds. After the constitutional amendment was passed by voters, some Ohio legislators sought to curtail judges’ ability to block these laws and interpret the constitutional amendment, but these efforts did not progress.

Status of Litigation in States with State Supreme Court Precedent Protecting the Right to Abortion

Alaska

In 1997, the Alaska Supreme Court found that the state constitutional right to privacy protects the right to abortion. The state has no gestational limit on abortion, however, other restrictions are still in effect.

Advocates in Alaska are challenging a law that limits abortion provision to physicians, using previous state supreme court precedent as the basis for their challenge. This requirement was originally blocked by a preliminary injunction in 2021 and in September 2024, a state trial court ruled that the requirement violates the constitutional protection for the right to abortion.

Kansas

In 2019, the Kansas Supreme Court found that the Kansas Bill of Rights includes the right to abortion. The gestational limit in the state is 22 weeks LMP (last menstrual period), other restrictions are still in effect.

In Kansas, advocates are challenging a 24-hour waiting period law that is temporarily blocked due to a court order while litigation proceeds and a law banning advanced practice registered nurses from providing medication abortion care. Advocates in Kansas have also used Kansas Supreme Court precedent to successfully challenge laws that limit the provision of abortion care to physicians and require ultrasounds before an abortion, as well as in-person dispensing of medication abortion.

Montana

In 1999, the Montana Supreme Court found that the state constitution protects the right to abortion. In 2024, the Montana Supreme Court reaffirmed this protection.

In addition, voters approved an amendment in November 2024 recognizing an individual’s right to make decisions about pregnancy, including the right to abortion. It states that “[t]his right shall not be burdened unless justified by a compelling government interest achieved by the least restrictive means.”

The gestational limit in the state is fetal viability, however, a state parental consent law is still in effect.

Abortion providers in Montana are challenging a law that excluded abortion coverage from the state’s Medicaid program, relying on previous Montana Supreme Court precedent that held that the state constitutional protection for privacy includes a protection for the right to abortion, instead of relying on the state’s newly passed constitutional amendment, since the challenge was underway before the constitutional amendment passed. In March 2025, a trial court ruled that this restriction is unconstitutional and permanently blocked it. Additionally, the Montana Supreme Court recently concluded in a different case that was also brought by abortion providers, that restrictions including an in-person dispensing requirement, a 24-hour waiting period, and a ban on telemedicine for abortion were unconstitutional. These restrictions are no longer in effect.

On July 4, President Trump signed into law a budget reconciliation package once called the “One Big, Beautiful Bill” that made major reductions in federal health care spending to offset part of the costs of extending expiring tax cuts. The Congressional Budget Office’s (CBO) latest cost estimate shows that the reconciliation package would reduce federal Medicaid spending over a decade by an estimated $911 billion (after accounting for interactions that produce overlapping reductions across different provisions of the law) and increase the number of uninsured people by 10 million. Building on prior KFF analysis of the House-passed reconciliation bill, this analysis allocates CBO’s federal spending reductions in the enacted reconciliation package across the states. The Medicaid reconciliation provisions are numerous and complicated, but the majority of federal savings stem from work requirements for the Affordable Care Act (ACA) expansion group, limiting states’ ability to raise the state share of Medicaid revenues through provider taxes, restricting state-directed payments to hospitals, nursing facilities, and other providers, and increasing barriers to enrolling in and renewing Medicaid coverage.

This analysis allocates the CBO’s estimated reduction in federal spending across states based on KFF’s state-level data and where possible, prior modeling work; and shows the federal spending reductions relative to KFF’s projections of federal spending by state under current law. KFF allocates the spending reductions provision-by-provision, pulling in a variety of data sources on which states are estimated to be most affected by each provision (see Methods). The total Medicaid spending cuts, nationally and by state, equal the sum of spending changes for each Medicaid provision ($990 billion over 10 years) less KFF’s estimate of the CBO interaction effects that are tied to Medicaid interactions ($79 billion over 10 years, see Methods). KFF did not apply the interaction effects to the estimated effects for each provision because it is unknown which provisions are driving CBO’s estimated interactions. The estimates exclude the $50 billion in funding for state grants through a Rural Health Transformation Program because it is highly uncertain how those funds will be allocated across the states.

CBO has not published updated estimates of the number of people who would lose Medicaid under the reconciliation package once called the “One Big, Beautiful Bill,” so this analysis does not include updated enrollment estimates like those included in KFF’s analysis of the House-passed reconciliation bill. CBO’s most recent estimate of Medicaid enrollment loss from an earlier version of the House reconciliation bill was 10.3 million people in 2034, which was associated with a $625 billion decrease in Medicaid spending (reflecting preliminary estimates prepared for the House Committee on Energy and Commerce). Given the Medicaid spending reductions are considerably larger in the enacted reconciliation package, more than 10.3 million people are likely to lose Medicaid.

This analysis does not predict how states will respond to federal policy changes, and anticipating how states will respond to Medicaid changes is a major source of uncertainty in CBO’s cost estimates. Instead of making state-by-state predictions, CBO generates a national figure by estimating the percent of the affected population that lives in states with different anticipated types of policy responses. For example, different states might choose to implement a work requirement with reporting requirements that are easier or harder to comply with. In estimating the costs of the legislation, CBO assumes that in aggregate, states would replace half of reduced federal funds with their own resources in response to provisions that reduce the resources available to states, such as limits on provider taxes. For provisions that reduce enrollment but don’t affect the division of costs between the federal and state governments, such as work requirements, CBO estimates that the federal and state Medicaid spending would go down. However, those assumptions reflect states’ responses as a whole and are likely to vary and may not apply in all states.

To the extent that states’ responses are far different from the overall average response, changes in federal Medicaid spending will be larger or smaller than what is shown here. States could make further Medicaid cuts, which would result in spending reductions greater than is estimated here and further reduce states’ Medicaid spending. Alternatively, states could increase their spending on Medicaid to mitigate the effects of federal cuts, which could result in spending reductions that are smaller than is estimated here. This analysis illustrates the potential variation by showing a range of spending effects in each state, varying by plus or minus 25% from the CBO estimated midpoint.

Key Take-Aways

• After accounting for CBO’s estimated interactions, KFF estimates that the enacted reconciliation package would reduce federal Medicaid spending by $911 billion. (Without accounting for interactions, the total is $990 billion, see Methods).
• The five biggest sources of Medicaid savings in the reconciliation package sum to $851 billion in savings, which is 86% of the gross savings (before accounting for interactions) and include:
  • Mandating that adults who are eligible for Medicaid through the ACA expansion meet work and reporting requirements ($326 billion),
  • Establishing a moratorium on new or increased provider taxes and reducing existing provider taxes in expansion states ($191 billion),
  • Revising the payment limit for state directed payments ($149 billion),
  • Increasing the frequency of eligibility redeterminations for the ACA expansion group ($63 billion).  
• Provisions that would only apply to states that have adopted the ACA expansion account for $526 billion, over half of the total gross federal spending reductions.
• Over three-quarters (76%) of the ten-year reductions in federal Medicaid spending in the reconciliation package would occur in the final five years of the period. While policy effects do typically compound overtime, many of the health care spending reductions are also backloaded and occur from 2030 through 2034.
• Federal cuts to states of $911 billion over 10 years would represent 14% of federal spending on Medicaid over the period. The spending cuts vary by state; Louisiana, Illinois, Nevada, and Oregon are the most heavily affected with spending cuts of 19% or more over the period.

Background on the U.S. and CEPI

• The Coalition for Epidemic Preparedness Innovations (CEPI) aims to accelerate the development of vaccines and other technologies to prepare for and respond to epidemic and pandemic threats. Pooling and leveraging contributions from more than 30 governments, philanthropic foundations, and private sector partners, CEPI invests to drive research and development into vaccine and therapeutic candidates against high-threat pathogens. It also works to strengthen global laboratory and vaccine manufacturer networks and regulatory environments and to research and support vaccine safety. A core focus is its “100 Days Mission”, an effort to reduce the time it takes to develop vaccines and other countermeasures during outbreaks with pandemic potential.
• Since its founding in 2017, CEPI contributed to the first licensed vaccine for Chikungunya; is supporting the development of vaccines for Lassa fever, MERS, Nipah virus and Rift Valley fever, all of them currently in clinical trials; and aided in the development of seven COVID-19 vaccines that were licensed for use.
• The U.S. government made its first financial contribution to CEPI in 2020 and has thus far invested $217 million in the organization. In January of this year, CEPI and the U.S. International Development Finance Corporation (DFC) announced an MOU to collaborate on aligning vaccine investments, among other activities. In May, CEPI and the U.S. Department of Defense signed a new agreement to enable collaboration on projects to expand protection against disease outbreaks, including a project to advance a therapeutic product against Nipah virus that. CEPI has also collaborated with the U.S. Biomedical Advanced Research and Development Agency (BARDA) on emergency response and vaccine development for filoviruses, particularly Ebola Zaire, Ebola Sudan, and Marburg. The FDA is a member of CEPI’s Joint Coordination Group and the overall relationship between CEPI and the U.S. government had been managed by USAID, which has held the U.S. government seat on the CEPI Investors Council.
• CEPI reports that it has contributed significantly to the U.S. economy through its funding of U.S.-based vaccine developers and that this funding far exceeds the amount of funding it has received from the U.S. government.
• CEPI replenishes funding every five years. For the last replenishment round, held in 2022, the U.S. pledged $150 million over five years, which has been exceeded. The U.S. accounts for approximately 6% of total contributions received by CEPI to date.

Current Status of U.S. Support for CEPI

• Funding: In FY 2024, Congress approved up to $100 million in funding to be allocated to CEPI. The FY 2025 Continuing Resolution that passed in March carried forward language from the prior year again stating that up to $100 million could be provided to the organization. CEPI has not yet received its FY24 funds, and it is not yet known if or how much funding will be provided for FY25.
• Foreign aid review/freeze: The foreign aid review’s stop-work order initially froze all U.S. bilateral programming but was not applied to CEPI or other multilateral institutions. The administration subsequently announced that it canceled 86% of all USAID awards. KFF analysis finds that of 770 global health awards identified, 80% are listed as terminated, including the CEPI contract. CEPI reports that it has not received a termination notice.
• International organizations review. A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, is currently underway. Per the order, the purpose of the review is to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed.”
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department, including remaining global health activities which would be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan.

What to Watch

• Results of foreign aid and international organization reviews: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), and the outcome of the review of international organizations is expected later this year. It is unknown whether there will be any recommendations related to U.S. support for or engagement with CEPI, and how or if Congress will respond to any such recommendations.
• Reorganization. While the administration has notified Congress that it intends to retain and integrate certain USAID activities into the State Department’s GHSD, no additional information is available on what this would mean for the relationship with CEPI.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, and does not include funding for CEPI. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas from the rescission though it is not yet known if CEPI will be exempted.

Background on the U.S. and Gavi

• Gavi, the Vaccine Alliance (Gavi), is an independent public-private, multilateral financing entity created in 2000. It raises and pools resources from multiple donors and in turn, disburses approximately $1.7 billion per year to support procurement and distribution of vaccines in low- and middle-income countries (LMICs).
• Gavi supports vaccines against 20 infectious diseases, and hosts the global emergency vaccine stockpiles against Ebola, yellow fever, meningitis, and cholera. By playing a market shaping role through pooled procurement, demand forecasting, support for regional manufacturing capacity, and other strategies, Gavi helps to drive down prices for vaccines in LMICs.
• Gavi reports that it has helped to immunize more than 1.1 billion children in 78 LMICs, preventing more than 18.8 million deaths, and generating economic benefits estimated at more than $250 billion, between 2000-2023.
• The U.S. government was one of the original donors to Gavi, and currently accounts for 13% of its funding, making it Gavi’s third largest contributor. Gavi also has a donor liquidity partnership with the U.S. International Development Finance Corporation (DFC) allowing Gavi to quickly access up to $1 billion from a “Rapid Financing Facility” to support routine immunization and pandemic response, backed by forthcoming donor pledges.  Additionally, the U.S. was the largest donor to COVAX, the international effort housed at Gavi that supported the development, procurement, and delivery of COVID-19 vaccines to LMICs (COVAX ended in 2023).
• Only LMICs whose most recent Gross National Income (GNI) per capita is below a certain threshold are eligible for Gavi assistance (54 countries in 2024). Countries are required to co-finance a portion of their vaccines on a sliding scale. To date, 19 countries have graduated from Gavi assistance.
• Gavi has been the primary mechanism by which the U.S. government supports the procurement of vaccines for LMICs (in addition to U.S. support for polio vaccination through the Global Polio Eradication Initiative). USAID’s bilateral maternal and child health program has complemented Gavi by supporting in-country capacity building and immunization campaigns.
• Every five years, Gavi replenishes funding through “pledging conferences”. The previous replenishment, for 2021-2025, generated $10.5 billion. For the 2026-2030 period, Gavi is seeking to raise $9 billion in new funding (towards a budget of $11.9 billion) which it estimates would save an additional 8-9 million lives by immunizing an additional 500 million children by 2030

Current Status of U.S. Support for Gavi:

• Funding: The U.S. provides funding to Gavi as part of its maternal and child health program. In FY 2024, U.S. funding for Gavi was $300 million. The FY 2025 Continuing Resolution that passed in March included level funding of $300 million, which marks (and would fulfill) the first year of Gavi’s new pledge period. The administration’s FY 2026 budget request does not include funding for Gavi and, while final funding levels are determined by Congress, Secretary of Health and Human Services Robert F. Kennedy Jr. has said that the U.S. will not provide additional funding to Gavi (see “Replenishment” below).
• U.S. Representation on the Gavi Board: The U.S. also plays a role in Gavi’s governance and oversight, sharing one of the donor government board seats on Gavi’s 28-member Board, and currently serving as the Board member for the seat.
• Foreign aid review/freeze: The foreign aid review’s stop-work order initially froze all U.S. bilateral programming but was not applied to Gavi or other multilateral institutions. The administration subsequently announced that it canceled 86% of all USAID awards. KFF analysis finds that of 770 global health awards identified, 80% are listed as terminated, including the main Gavi contract as well as the COVAX contract. Gavi reports that it has not received a termination notice for its main contract, although it did receive one for COVAX (all U.S. funding was already disbursed to COVAX in 2021).
• International organizations review: A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, is currently underway. Per the order, the purpose of the review is to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed”.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department, including remaining global health activities which would be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). Delivery of lifesaving vaccines is listed among the USAID activities to be continued. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan.
• Potential impact on health outcomes: The loss of U.S. support for Gavi would affect procurement of vaccines for LMICs, with particular impact on children. Gavi estimates that loss of funding could result in 75 million children not receiving routine vaccinations over the next five years, leading to more than 1.2 million children dying as a result. Reductions in vaccine stockpiles could also impact outbreak control.

What to Watch

• Results of foreign aid and international organization reviews: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), and the outcome of the review of international organizations is expected later this year. It is unknown whether there will be any recommendations related to U.S. support for or engagement with Gavi, and how or if Congress will respond to any such recommendations.
• Reorganization: While the administration has notified Congress that it intends to retain and integrate USAID’s delivery of lifesaving vaccines activities into the State Department’s GHSD, no additional information is available on what this would mean for the relationship with Gavi.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, and does not include funding for Gavi. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas, including Gavi as part of maternal and child health funding, from the rescission.
• Replenishment: Gavi’s June 2025 pledging conference raised $9 billion in funding towards its $11.9 billion target. Last year, the Biden administration pledged at least $1.58 billion over five years to Gavi’s replenishment. However, Secretary Kennedy announced that the U.S. will not provide additional funding to Gavi unless it changes its evaluation of vaccine science and safety, among other issues. In response, Gavi has stated that it relies on WHO’s independent, science-based, global vaccine evaluation and recommendation process. In addition, individual country requests for vaccine support from Gavi are made in line with their own national immunization policies. While final U.S. funding amounts are determined by Congress, it remains to be seen how this will unfold over the next year.

Background on U.S. Global Family Planning & Reproductive Health (FP/RH) Efforts

• The U.S. government has supported FP/RH efforts for 60 years and has been the largest donor to the sector. It has also been one of the largest purchasers and distributors of contraceptives internationally.
• Still, each year, about 260,000 women die from complications during pregnancy and childbirth, almost all in low- and middle-income countries. Almost one-third of these deaths could be prevented with greater access to contraception. Worldwide, an estimated 257 million women have an unmet need for modern contraception.
• Recent decades have seen major gains in access to family planning and reproductive health services. The U.S. government has contributed significantly to this progress, reporting that in the 41 countries it supports, modern contraceptive prevalence has increased from less than 10% in 1965 to 34% in 2023 and family size fell from more than 6 to 3.9. The program estimated that it would reach up to 24 million women and couples with contraceptive services and supplies, helping to prevent 14,000 maternal deaths and 8.1 million unintended pregnancies, in 2023.
• USAID has served as the lead U.S. implementing agency for FP/RH activities, working in 41 countries, with focused effort in 29 high-need countries and the Francophone West African region. The CDC has also supported some global FP/RH activities primarily through research, surveillance and technical assistance. While Congress has funded them separately, USAID’s FP/RH and maternal and child health programs coordinated efforts, working in many of the same countries.
• The U.S. role in global FP/RH has often been contested, influenced by differing views and political debates primarily related to abortion. As a result, U.S. funding for FP/RH is governed by several legislative and policy requirements, including the Mexico City Policy (which has been implemented and rescinded along Presidential party lines and was significantly expanded by the first Trump administration), the Helms Amendment, and the Kemp-Kasten Amendment.
• The FY 2025 Continuing Resolution that passed in March included level funding for FP/RH activities at USAID of $607.5 million (and level funding for contributions to UNFPA, the primary international agency supporting FP/RH programs worldwide).  The administration’s FY 2026 budget request does not include any funding for bilateral family planning or UNFPA (final appropriation levels are determined by Congress).

Current Status of U.S. FP/RH Programs

The following administration actions have had a significant impact on FP/RH program operations:

• Funding freeze/stop-work order: The stop-work order initially froze all FP/RH programming and services, halting USAID’s FP/RH programming including procurement and delivery of contraceptive commodities. Because the order halted payments, many implementers had to let go of staff and end some services.
• Limited waiver: While the State Department issued a waiver of the stop-work order allowing certain “life-saving services” to continue, family planning services were specifically prohibited from continuation, including in the blanket humanitarian waiver issued on January 28 and the limited global health waiver issued on February 4.
• Dissolution of USAID: As the main government implementer of FP/RH efforts, the dissolution of USAID and loss of most staff have significantly affected FP/RH implementation capacity and operations. In addition, recent announcements of reductions at CDC could further affect global FP/RH efforts.
• Canceled awards: It was recently reported that the administration has canceled 86% of all USAID awards. KFF analysis finds that of the 770 global health awards identified, 233 included FP/RH activities, 85% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court has not stopped the government from canceling awards.
• Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. However, FP/RH is not included in the list of activities to be maintained.
• Policy restrictions: The Trump administration reinstated the expanded Mexico City Policy on January 24, and an implementation plan is expected soon. It also directed a program review under the Kemp-Kasten Amendment, which has been used in the past to prohibit funding for UNFPA, and recently announced its intention to do so going forward. UNFPA also reports that more than 40 humanitarian projects, totaling approximately $335 million, have already been canceled by the U.S.

Impact on FP/RH Services and Outcomes

• A recent rapid assessment survey of 108 WHO country offices found that more than four in ten reported moderate or severe disruptions to FP and contraception services, with 38% reporting such disruptions for commodities specifically, due to the U.S. foreign aid freeze and other shortages.
• A recent estimate found that cessation of U.S. FP/RH funding for 3 months would mean 11.7 million women and girls would be denied access to contraceptive services, resulting in 4.2 million unintended pregnancies and 8,340 deaths from complications during pregnancy and childbirth (i.e., maternal deaths), while ending support for a year could result in 17.1 million unintended pregnancies, including 5.2 million unsafe abortions and 34,000 maternal deaths.
• A recent modeling study found that cessation of U.S. FP/RH funding for contraceptives alone could result in an additional 40-55 million unintended pregnancies and an additional 12-16 million unsafe abortions between 2025 and 2040.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), but it has already signaled that it will seek to discontinue FP/RH programs. It is unknown how or if Congress will respond to this recommendation.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, and does not include funding for family planning. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million, and while it exempted some program areas from the rescission, most or all of the funding to be rescinded will come from family planning.
• Policy restrictions: The administration may seek to institute additional policy restrictions on other U.S.-funded global health and development programs regarding abortion and family planning services, such as a further expansion of the Mexico City Policy.

 Background on the U.S. and the Global Fund

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

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

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

What to Watch

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

Background on U.S. Global Health Security Efforts

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

Current Status of U.S. Global Health Security Programs

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

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

Impact on GHS Services and Outcomes

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

What to Watch

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

Background on PMI

• The U.S. government has been involved in global malaria activities since the 1950s. In 2005, the President’s Malaria Initiative (PMI) was launched to scale up efforts to address malaria in the hardest hit African countries.
• Malaria is a life-threatening disease that is spread to humans by mosquitoes. There are approximately 263 million malaria cases and 600,000 deaths each year; the majority of malaria deaths are among children under age five.
• PMI is credited with helping to save 11.7 million lives and prevent 2.1 billion malaria cases since 2000. Indeed, since 2006, in countries where PMI works, global efforts have supported a 29% decrease in malaria case rates and a 48% decline in deaths. The introduction of two malaria vaccines in 2021 and 2023, respectively, has increased optimism in the potential to further strengthen global malaria control.
• The FY 2025 Continuing Resolution that passed in March included level funding for PMI and other malaria activities at USAID and CDC of $805 million (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria). The U.S. has been the top donor government to malaria efforts, through PMI and contributions to the Global Fund.  The administration’s FY 2026 budget request includes $424 million for malaria, a decrease of $381 million (final appropriation levels are determined by Congress).
• Overseen by a U.S. Global Malaria Coordinator, a position created by Congress in 2008 to be appointed by the President and based at USAID, PMI is an interagency initiative led by USAID in partnership with CDC. Efforts have been focused in 30 countries that account for 90% of the world’s malaria cases and deaths.

Current Status of PMI

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

• Funding freeze/stop-work order: The stop-work order initially froze all PMI programming and services, halting existing PMI activities, including bed net provision, residual spraying and delivery of antimalarial medicines. Because the order halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited waiver: Malaria programs received a limited waiver on February 4 allowing “life-saving services” to continue, defined as those services that “must resume within 30 days to ensure malaria diagnosis and treatment, as well as prevention through distribution of nets and indoor residual spraying targeting highest burden areas…and lifesaving malaria medicines for pregnant women and children”. Even with the waiver, services remain disrupted and implementers have faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: USAID was the main government implementing agency for malaria efforts, obligating almost all bilateral malaria assistance in FY 2023 (96%). Without USAID and most of its staff, PMI’s implementation capacity has been affected. In addition, recent announcements of reductions at CDC could further affect global malaria efforts.
• Canceled awards: It was recently reported that the administration has canceled 86% of all USAID awards. KFF analysis finds that of the 770 global health awards identified, 157 included malaria activities, 80% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court has not stopped the government from canceling awards.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan.

Impact on PMI Services and Outcomes

• An internal USAID memo reported that an additional 12.5-17.9 million malaria cases and an additional 71,000-166,000 deaths could occur annually if PMI was halted permanently.
• A recent modeling study found that PMI could help to avert almost 15 million malaria cases and 107,000 deaths in 2025, gains that would be threatened by the foreign aid freeze, cancelations of projects, and uncertainty of funding.
• A recent rapid assessment survey of 108 WHO country offices found that of the 64 malaria-endemic countries surveyed, more than half reported moderate or severe disruptions to malaria services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• As of early April 2025, almost 30% of planned insecticide treated net (ITN) distribution campaigns, designed to reach 425 million people, were off-track or at risk of being delayed due to funding shortages. Countries also face limited supply of key commodities including six countries with only a 3-month supply of malaria rapid diagnostic tests (RDTs) and five countries with only a 3-month supply of artemisinin-based combination therapy (ACT). Reductions in funding also threaten investments in new and improved malaria prevention, diagnostic, and treatment interventions.
• The timing of these disruptions poses significant risks for malaria efforts given that malaria season has begun in much of Africa, requiring the need for seasonal malaria campaigns to protect millions of people. In a court filing challenging the funding freeze, for example, a major U.S. implementer reported that it had already had to delay the start of anti-malarial campaigns in Africa.

What to Watch

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