In a given year, a small portion of the population is responsible for a very large percentage of total health spending. This collection of charts explores the variation in health spending across the population through an analysis of 2023 Medical Expenditure Panel Survey (MEPS) data. The analysis finds that five percent of the population accounted for nearly half of all health spending, spending an average of $72,918 annually in 2023. People with health spending in the top one percent spent an average of $150,467 per year.

The analysis also examines spending variation by age, gender, race, insurance coverage status and presence of certain health conditions. Adults who have been diagnosed with a serious or chronic disease have significantly higher out-of-pocket spending.

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

Summary

Actions taken by the Trump administration and Congress will likely have major impacts on health and health care for immigrant families, including children. About one in four children in the U.S. has at least one immigrant parent, and the vast majority of these children are U.S. citizens. President Trump’s increased immigration enforcement activity has contributed to significant levels of fear and uncertainty among the immigrant community, which can negatively affect the health and well-being of immigrant families and make them more reluctant to access health coverage as well as health care. Longstanding research also shows that such fears can have lifelong negative impacts on the physical and mental health of children.

This brief provides data on the health and health care experiences of immigrant parents and their children in the U.S. amid the current policy environment. Immigrant parents include naturalized citizens, lawfully present immigrants, and likely undocumented immigrants who report having a child under age 18 living in the home with them. As noted, the vast majority of children with an immigrant parent are citizens (in some cases by birthright citizenship, which President Trump has sought to restrict in a case currently before the Supreme Court). This brief is based on a KFF survey conducted in partnership with The New York Times in Fall 2025, prior to the recent ramp up of public Immigration and Customs Enforcement (ICE) activity in Minneapolis and several other areas of the country. It builds on the 2023 KFF/LA Times Survey of Immigrants and two additional surveys conducted by KFF in 2024 and  2025. Separate reports from the Fall 2025 survey examine immigrants’ health care experiences overall, experiences amid increased immigration enforcement, and the political implications of immigrant voters’ views on immigration enforcement.

Key takeaways include:

• Immigrant parents report experiencing increased economic challenges, including paying for health care. About half (52%) of immigrant parents say that it has been harder to earn a living since January 2025. Additionally, over half (55%) say they have had problems paying for health care, housing, or food in the past 12 months, with these shares increasing since 2023.
• Immigration-related fears are negatively impacting the health of immigrant parents and their children, including citizens and lawfully present immigrants. About a quarter of immigrant parents (27%), including six in ten (60%) likely undocumented immigrant parents, say that any of their children have expressed worries or concerns about the possibility of something bad happening to someone in their family because they are an immigrant.Nearly half (47%) of immigrant parents report experiencing negative health impacts due to immigration-related worries since January 2025, and about one in five (18%) say that their child’s well-being has been impacted.
• Immigrant parents report health care access challenges for themselves and their children. About one in five (22%) immigrant parents report being uninsured, twice the share of those without a child in the home (11%). About one in seven (15%) immigrant parents say they have a child who is uninsured, with this share rising to about a quarter (27%) among parents who are likely undocumented and to about one in five of those with lower incomes (annual household income of less than $40,000)  (22%) or limited English proficiency (LEP) (21%).
• Three in ten (30%) immigrant parents say any of their children missed, delayed, or skipped health care in the past 12 months due to immigration-related fears (14%), not being able to find services at a convenient time or location (13%), or cost or lack of insurance (12%). This includes about six in ten (58%) likely undocumented immigrant parents as well as 23% of naturalized citizen parents and 26% of lawfully present immigrant parents who say any of their children missed, delayed, or skipped care.

Economic Challenges

About half (52%) of immigrant parents say that it has been harder to earn a living since January 2025, and over half (55%) say that they have had problems paying for health care, housing, or food in the past 12 months. These shares are higher compared to those without a child in the home, among whom 45% say it has been harder to earn a living and 42% report problems paying for health care, housing, or food. Among immigrant parents, the shares reporting problems paying for basic needs increased between 2023 and 2025, rising from 22% to 42% for health care, from 22% to 36% for rent or mortgage, and from 21% to 32% for food.

Impacts of Immigration-Related Fears on Health

About a quarter of immigrant parents (27%), including about one in five naturalized citizens (20%) and lawfully present immigrants (23%), say that any of their children have expressed worries or concerns about the possibility of something bad happening to someone in their family because they are an immigrant (Figure 2). Among likely undocumented parents, the share rises to 60%. Additionally, about four in ten Hispanic immigrant parents (39%) as well as those with household incomes of less than $40,000 per year (41%) say their children have expressed these worries or concerns.

Nearly half (47%) of immigrant parents say they have experienced negative health impacts due to immigration-related worries since January 2025 (Figure 3). These negative health impacts include increased stress, anxiety, or sadness (47%); problems sleeping or eating (29%); or worsening health conditions like diabetes or high blood pressure (19%) due to immigration-related worries.Reported negative health impacts are higher among parents (47%) compared to those without a child in the home (35%).

About one in five (18%) immigrant parents say their child’s well-being has been negatively impacted by immigration-related worries since January 2025 (Figure 4). These impacts include problems sleeping or eating (14%); changes in school performance or attendance (12%); or behavior problems (12%). Reports of impacts on children are particularly high among likely undocumented immigrant parents (46%), parents with lower incomes (30%), and immigrant parents with LEP (24%), although over one in ten naturalized citizen (12%) and lawfully present immigrant (15%) parents report their children experienced at least one negative impact.

Health Coverage and Access to Health Care

Immigrant parents are twice as likely to be uninsured as their counterparts without a child in the home (22% vs. 11%), and 15% of immigrant parents report having at least one uninsured child as of 2025. The share of immigrant parents who report having an uninsured child rises to about a quarter (27%) among those who are likely undocumented and about one in five of those with lower incomes (22%) or LEP (21%) (Figure 5). 

Three in ten (30%) immigrant parents say any of their children missed, delayed or skipped health care in the past 12 months due to immigration-related fears (14%), not being able to find services at a convenient time or location (13%), or cost or lack of insurance (12%) (Figure 6). While rates of delayed or skipped health care for children are higher among immigrant parents who are likely undocumented (58%), with 43% citing immigration concerns, about one in four naturalized citizen (23%) and lawfully present (26%) parents also say their children delayed or skipped care, with about one in ten identifying immigration concerns as a reason (8% and 10%, respectively).

Further, one in five (20%) immigrant parents say they or a family member have avoided seeking medical care since January 2025 due to immigration-related concerns (Figure 7). This is twice the share of those who are not parents (9%). There have been reports of increased presence of ICE (Immigration and Customs Enforcement) at health care facilities following the Trump administration’s  reversal of previous policy that had protected against enforcement in these and other “sensitive locations” like schools and places of worship. These actions could further exacerbate fears among immigrant families and may lead to greater avoidance of medical care and other activities going forward for parents and children.

States are facing constrained budgets, putting pressure on HIV care and prevention programs, including the Ryan White HIV/AIDS Program. Ryan White, the nation’s HIV safety-net, is funded each year through discretionary federal appropriations, state dollars, and other sources. However, funding does not necessarily match the number of people who need support or the cost of services.

The largest component of Ryan White provides grants to states, including for their AIDS Drug Assistance Programs (ADAPs), which provide HIV treatment and insurance assistance for people with HIV. In the past, ADAPs have used waiting lists and other cost-containment measures when programs could not meet the needs of all those eligible, and in the early 2000s, waiting lists were common. Significant waiting lists were last cleared with an influx of emergency federal funding in 2013 and then were used occasionally for a few years. They have not been used for over a decade and, to date, have not returned. However, several states facing budget pressures have recently moved to institute other cost-containment measures, including restricting eligibility and scope of services, and some are considering waiting lists for the future.  This represents the first time such broad cost-containment measures have been taken since the waitlist era.

Ultimately, such changes could result in people with HIV losing access to care and treatment, which could worsen health outcomes (increasing morbidity and mortality) and leading to new HIV infections (four in ten new HIV transmissions are associated with someone who is aware of their HIV status but not in care).

State ADAPs Respond to Strain by Limiting Enrollment and Services Offered

Florida recently announced changes to its ADAP, which would dramatically limit eligibility and scope of assistance. Specifically, the state plans to reduce income¹ eligibility for the program from 400% of the federal poverty level (FPL) to 130% FPL (for an individual, which is the equivalent of eligibility decreasing from a maximum income of $63,840 to $20,748 annually).

Additionally, the state plans to remove Biktarvy from its formulary. Biktarvy is the most widely prescribed antiretroviral (ARV) medication nationally (accounting for 52% of the U.S. ARV market) and the only single tablet regimen (STR) included among the national HIV treatment guidelines list of recommended initial treatment regimens. Some studies have shown that STRs improve adherence by reducing pill burden.

The state also plans to roll back its insurance assistance program. ADAPs can help cover insurance costs in addition to directly purchasing medications. Ending insurance assistance poses unique challenges, as insurance coverage allows individuals to meet both HIV-related and other health care needs and helps protect clients in the face of unexpected medical costs (e.g. through out-of-pocket maximums).² With expiration of enhanced Affordable Care Act premium tax credits, out-of-pocket premiums for people in ACA plans are increasing substantially this year.

The changes in Florida have received significant push back from advocates, patients, and providers, and the state was sued for proceeding with these changes without formal rule making. (The state then issued a proposed rule which it followed with emergency rulemaking. Litigation continues seeking to block implementation).

Florida, however, is not alone. New data from the National Association of State and Territorial AIDS Directors (NASTAD) indicate that 23 states (including Washinton, D.C.) have implemented or are considering ADAP cost-containment measures.³ Eighteen (18) ADAPs, including Florida‘s, have already made or are making changes and five additional states report that they are considering introducing such measures in the future. Further, 12 of the 18 states already implementing cost-containment measures are considering additional changes for the future.

For example, in addition to Florida, Pennsylvania, Kansas, Delaware, and Rhode Island have also reduced income eligibility for their programs (though to a lesser degree). Other changes states are exploring or implementing include reducing formularies (though, so far, none as consequential as removing Biktarvy), reducing funding for medical and support services, making recertification more stringent (which can create churn and lead to program disenrollment), implementing annual client spending caps, and restricting or ending health insurance assistance.

To date, no state has implemented a waiting list, a measure widely seen as a last resort. However, Arkansas, Louisiana, and New Jersey report considering implementing one as a future cost-containment measure.

Multiple Factors Are Exerting Budget Pressures on ADAP

There are a range of factors affecting ADAP budgets. These include, but are not limited to, the following:

Federal ADAP Funding Not Keeping Pace With Inflation

Since 1996, Congress has allocated (or “earmarked”) a set amount of funding for ADAPs during the annual appropriations process. After modest funding levels in the late 1990s, followed by significant growth in the early 2000s, ADAP inflation-adjusted appropriations have declined by 31% since 2005.⁴ The decline is largely attributable to more than a decade of flat funding in nominal dollars. When adjusted to 1996 dollars, the FY25 appropriation ($438.8 million) has similar purchasing power as the program’s FY1999 funding level ($434.0 million).⁵ In other words, in the last 20 years, ADAP funding has not kept pace with inflation, even before accounting for enrollment growth and increased costs (discussed below).

In the NASTAD report ADAPs identified growing client enrollment, growing drug costs, and rising insurance costs as the top three drivers of budget concerns. These concerns are explored further below:

Increased Client Enrollment

While modern era federal ADAP funding has not kept pace with inflation, the number of ADAP clients served has increased significantly. The number of clients served increased by 56% from 2007 (the first year with available data for the full year) to 2024 (the most recent year with available data), rising from 165,382⁶ to 257,644 clients served. Adjusted for inflation, appropriations per client served dropped from about $3,600 in 2007 to approximately $1,700 in 2024. Additionally, the national HIV treatment guidelines have evolved to recommend HIV treatment at the time of diagnosis -as opposed to starting at signs of disease progression- which has led to more people with HIV having an indication for treatment.

Rising HIV Drug Costs

Another factor impeding the reach of ADAP dollars is the increasing cost of drugs for HIV treatment. A recent analysis found that the average wholesale price (AWP) of recommended initial antiretroviral regimes in 2012 ranged from an AWP of $24,970 to $35,160, increasing to $36,080 to $48,000 in 2018. Costs have generally increased since then. Data in the treatment guidelines show that the AWP for Biktarvy (again the number one treatment regimen for people with HIV and only STR recommended by the treatment guidelines start list) was $61,000 in 2025. The 2025 AWP for other recommended (two-pill) regimens ranged from $34,320 to $65,196. While ADAPs do not pay the full AWP because they have access to price discounts through the 340B drug pricing program and supplemental manufacturer rebates, increasing drug prices may still affect them; it is a main concern cited by ADAPs regarding cost challenges. Additionally, ADAPs ability to generate rebates (which make up a growing share of their budgets) through Medicare have diminished due to programmatic changes, including adoption of the out-of-pocket cap in Part D – by introducing the cap, ADAPs and other 340B entities, have less opportunity to generate rebates on claims because they make fewer cost-sharing payments.

Increased Insurance Premium Costs and Expiration of Enhanced Tax Credits

As mentioned above, ADAPs can also purchase health insurance for eligible clients. However, the cost of individual market coverage is on the rise, with the expiration of the enhanced premium tax credits being a particular driver and premium increases also playing a role.

ACA premium tax credits help make marketplace plans more affordable for people with low to moderate incomes. They were first enhanced as part of the American Rescue Plan Act in 2021 and extended by Congress through 2025, but have since expired due to the lack of a bipartisan Congressional agreement to continue them. The enhanced tax credits had improved insurance affordability for ADAPs purchasing coverage on behalf of clients, including for those previously eligible for the less generous ACA subsidies and, newly, for those with incomes over 400% FPL, a group for whom premium costs were limited to 8.5% of income. Without the enhanced credit those 100-400% FPL revert to the original, less generous, ACA tax credits and those over 400% FPL have lost financial assistance altogether. For enrollees keeping the same plan, expiration of the enhanced premium tax credits is estimated to more than double what subsidized enrollees previously paid annually for premiums—a 114% increase from an average of $888 in 2025 to $1,904 in 2026.

Additionally, after holding relatively steady since 2020, premiums increased steeply between 2025 and 2026, with the average premium cost for benchmark plans increasing by 26%⁷, with significant variation across states. Some southern states with high HIV prevalence saw especially large average increases (e.g. 33% in Florida and 35% in Texas). These premium increases occurred for a range of reasons including, but not limited to, higher health care costs, use of expensive GLP-1 drugs, the threat of tariffs, and the expiration of the enhanced premium tax credits. While the vast-majority of ADAP clients have modest incomes, these costs will be borne out most acutely for the 7% of clients served by insurance purchasing who have incomes over 400% FPL, a group who lost the enhanced tax credits that previously capped premium costs as a share of their income. ADAPs covering individuals in this higher income group face a two-fold setback – loss of enhanced tax credits and no protections against rising premiums. 

Additionally, individuals who lose ADAP insurance coverage due to cost-containment measures may find financing coverage independently more challenging due to reduced tax credit generosity and increases in premiums.

Looking Ahead

While ADAPs have sought to leverage additional state funds, drug rebates, and capture limited emergency and supplemental funding, these efforts have not remedied budget shortfalls, leading many to institute cost-containment measures. ADAPs may increasingly face budget pressures that could lead to additional such measures in the future. This could leave growing numbers of people with HIV ineligible for safety-net services, particularly if states further lower income eligibility limits or institute waiting lists. The expiration of enhanced tax credits amplifies these challenges, both increasing costs for programs and leaving those who are ineligible for ADAPs with fewer affordable alternatives. Limiting access to Ryan White services will in turn affect the ability of people with HIV to stay engaged in HIV treatment, a cornerstone of national efforts to address the HIV epidemic.

Endnotes

1. Except for cost-sharing assistance which will remain available for those up to 400% FPL. ↩︎
2. It is a federal requirement that insurance purchased through Ryan White be cost-effective compared to direct drug purchasing and  allows programs to generate 340B revenue.  ↩︎
3. 44 states, including DC, responded to the survey. In addition, information on FL was publicly available. It is possible, but unknown if, the remaining states are implementing or considering cost-containment measures. ↩︎
4. Adjusted using annualized CPI-U. ↩︎
5. Full year CPI-U data for 2026 not yet available. ↩︎
6. KFF and NASTAD. National ADAP Monitoring Project. 2009. https://www.kff.org/wp-content/uploads/2013/01/7861_es.pdf ↩︎
7. The second-lowest-cost silver (benchmark) premium for a 40-year-old in each county and weighted by county plan selections. ↩︎

With the expiration of the Affordable Care Act (ACA) Marketplace’s enhanced premium tax credits as of December 31, 2025, the average ACA enrollee who received a premium tax credit faces a doubling of their premium payments for the same plan. Older adults, who make up a large share of Marketplace enrollees, are disproportionately affected by the loss of enhanced premium tax credits. About one-third of all Marketplace enrollees (8 million people) were between ages 50 and 64 in 2023 (the most recent year of data available), constituting a sizeable portion of those purchasing Marketplace plans. The number of people with ACA Marketplace coverage generally increases with age, peaking at age 64, as the chart below shows.

Marketplace enrollees between the ages of 50 and 64 are disproportionately affected by the expiration of the enhanced premium tax credits, not just because they make up a large number of Marketplace enrollees, but also because the cost of Marketplace premiums tend to rise with age. Older ACA enrollees with annual incomes just above 400% of the federal poverty line (FPL) are expected to see the largest increases in premium payments.  Older adults also make up a relatively large share of ACA Marketplace enrollees with incomes above 400% FPL, who will no longer be eligible for any assistance with the expiration of the enhanced premium subsidies.

Why do older adults purchase ACA Marketplace plans?

People in their late 50s and early 60s rely on the ACA Marketplace for health insurance coverage for a variety of reasons. Across all ages, most Marketplace enrollees are working, but they often work in fields that frequently do not offer employer health insurance, are self-employed, or own or work at small businesses. Among direct purchase insurance enrollees in their early 60s, nearly half (45%) are working full or part time, but about a third (35%) are retired, and 21% are not working because of a disability, have caregiving responsibilities, or other reasons.

While people in the U.S. have been retiring at later ages in recent years, on average, many people retire earlier than expected and often do so involuntarily (e.g., because they are too sick to work, can no longer do physically demanding work, or were laid off and could not find new employment). A survey by the Employee Benefit Research Institute found that most people who retire early do so for reasons beyond their control, while two in five retired early because they felt they could afford to do so.

As the number and share of employers offering retiree health benefits to pre-Medicare retirees continues to shrink, fewer people who leave the workforce before age 65 have access to retiree health benefits through their former employers. In 2025, only 27% of large firms (with 200 or more workers) that offered health benefits also provided retiree coverage to at least some employees under age 65. For older adults without access to an employer-based plan, ACA coverage may be their only insurance option until they become eligible for Medicare at age 65.   

Why have older adults been disproportionately impacted by the expiration of enhanced premium tax credits?

Across all ages, on average, premium payments for subsidized enrollees are estimated to have more than doubled in 2026 for enrollees wanting to keep the same plan, rising an average of 114%, because of the expiration of the enhanced premium tax credits. However, some enrollees could have switched to a plan with a lower premium but higher deductible to lessen their premium payment increases. Around nine in 10 ACA enrollees have annual incomes less than 400% FPL and will therefore continue to receive some tax credit without the enhanced tax credits, but at a lower level of federal financial assistance; most enrollees over age 50 will likely continue to receive tax credits.

However, older, middle- and upper-income ACA enrollees are disproportionately affected by the spike in premium payments. This is for three main reasons. First, people ages 50-64 make up about half of individual market enrollees with incomes above 400% FPL, meaning they will not be eligible for any federal financial assistance without the enhanced premium tax credits. Second, because premiums in the ACA marketplace are higher for older than younger adults, this group faces unsubsidized premiums that are up to three times higher  than for younger enrollees. In 2026, unsubsidized benchmark premiums increased by 26% on average, the largest increase in eight years, driven in part by an expectation that healthier enrollees would drop coverage as the enhanced tax credits expire. As a result, older, middle- and upper-income enrollees faced a “double whammy” of both the loss of all federal premium financial assistance and an increase in the cost of unsubsidized premiums that is larger than other age groups.

Third, many ACA enrollees in their 50s and early 60s were already signed up for one of the lowest-premium plans available to them and therefore had limited options to switch to a lower-premium plan for the 2026 plan year. Of ACA Marketplace enrollees aged 50-64 not receiving cost-sharing reductions (and therefore likely with incomes over 250% of poverty), most (64%) were already enrolled in a bronze plan, 22% were in a gold plan, and just 13% were in a silver plan for the 2023 plan year. Those in a silver or gold plan in 2025 could have switched to a bronze plan for 2026 to mitigate the increase in premium payments but would then have a deductible much higher than their previous plan.

For 2026 health coverage, the average gold plan deductible is $1,722, the average silver plan deductible (without cost-sharing assistance) is $5,304, and the average bronze plan deductible is $7,476.

How much have premium payments increased for older ACA enrollees, now that enhanced tax credits expired?

On average, a 60-year-old with an income of $65,000 (just over four times the poverty level) pays $10,389 more annually ($865 per month) toward their premium now that enhanced premium tax credits have expired.

The national average annual unsubsidized premium payment for a 60-year-old in 2026 is $11,625 for the lowest-cost bronze plan, $15,914 for the benchmark silver plan, and $15,672 for the lowest-cost gold plan. (Due to “silver loading” unsubsidized silver plans are often priced similarly to gold, which is why few middle- or higher-income people, who are ineligible for cost-sharing reductions, are enrolled in silver plans).

On average, with enhanced premium tax credits, a 60-year-old spent 2% of their annual income of $65,000 on a bronze plan. However, without enhanced premium tax credits, the average bronze plan costs the same 60-year-old 18% of their annual income. Similarly, with enhanced premium tax credits, the average silver and gold plan would each cost a 60-year-old making $65,000 per year about 8.5% of their income. However, with the expiration of the enhanced premium tax credits, the average silver and gold plan would now cost nearly one-quarter (24%) of the same 60-year-old’s annual income.

Depending on location, some older enrollees could expect to pay less or more. The average annual unsubsidized 2026 premium for the lowest-cost bronze plan for a 60-year-old is highest in Wyoming ($20,005), West Virginia ($19,747), and Alaska ($17,045). By contrast, Maryland ($7,215), New York ($7,318), and Massachusetts ($8,002) have the lowest average unsubsidized bronze premiums for a 60-year-old.

An annual income at 401% FPL represents an annual salary of $62,757 for an individual in the contiguous United States. Because the cost of living is higher in Alaska and Hawaii, 401% of federal poverty is $78,396 and $72,140 for individuals there, respectively. In 46 states and the District of Columbia, a 60-year-old at 401% of poverty will see their average annual premium payment for a benchmark silver plan at least double without enhanced tax credits.

As seen in Figure 4, in 19 states, this person would see their premium payment at least triple on average for a benchmark silver plan, consuming more than 25% of annual income. States with the highest premium payment increases due to expired enhanced tax credits for a 60-year-old at 401% of poverty purchasing a benchmark silver plan are Wyoming ($22,452 increase per year), West Virginia ($22,006), and Alaska ($19,636). The smallest increases caused by the loss of enhanced tax credits for what enrollees pay annually for the benchmark silver plan are in New York ($4,469), Massachusetts ($4,728) and New Hampshire ($4,877).

In a major victory long sought after by abortion opponents, the federal government now has codified a ban on Medicaid funds that support care provided at Planned Parenthood clinics and other locations. Section 71113 of the 2025 Federal Budget Reconciliation Law, prevents Medicaid payments to certain reproductive health care entities that provide abortion care for one year from the date of enactment. This ban includes all services including contraceptive care, preventive care, and other services, not only abortion. Based on the criteria in the law, three entities, Planned Parenthood affiliates, Maine Family Planning and Health Imperatives—providers in 39 states—have been blocked from receiving federal Medicaid revenue. A handful of states, however, have announced they will fill in current gaps created by losses in federal funding to support access to care for their residents. These funds will enable providers to keep serving enrollees they care for in these states to differing degrees, but in the remaining states, the loss of Medicaid revenues will greatly limit their ability to continue to see Medicaid patients. This brief reviews the status of state commitments to funding reproductive health care providers affected by Section 71113 to date.  

While there is ongoing litigation challenging Section 71113, the provision is currently in effect but a final decision on the merits of these cases might come after July 2026, when the one-year funding ban is no longer in effect. After the enforcement of Section 71113 became effective for Planned Parenthood in September 2025, some Planned Parenthood affiliates offered services to Medicaid beneficiaries on a free or reduced-fee basis, allowing patients to continue receiving care regardless of their ability to pay. However, federal Medicaid funds are not flowing into the clinics, and only a handful of states have stepped in to provide funding to support care. In September 2025, Planned Parenthood said they covered the costs of care provided to most of their patients who use Medicaid — an estimated $45 million in care. However, the organization stated that these efforts are unsustainable over the long run. 

Planned Parenthood’s Role in Providing Family Planning Services to Medicaid Enrollees 

Planned Parenthood is a large provider of family planning services nationwide. Planned Parenthood affiliates maintain health centers in 46 states and the District of Columbia and provide services to over 2 million patients per year. Over half of Planned Parenthood’s patients rely on Medicaid for their health coverage, and a KFF analysis finds that nearly one in five (18%) Medicaid enrollees got their contraceptive care from a Planned Parenthood clinic in 2023 (Figure 1). This share is greater in states like California, and Wisconsin where nearly half and one third of female Medicaid enrollees who got contraceptive care went to a Planned Parenthood health clinic, respectively. Planned Parenthood health clinics are primarily located in rural or medically underserved communities, and sometimes are the only clinic in a community offering sexual and reproductive health care services including contraception. Due to the unique role Planned Parenthood plays in offering sexual and reproductive health care, research shows that Medicaid enrollees would be harmed if they were excluded from Medicaid reimbursement because they would face increased difficulties in accessing contraceptive methods, primary care, and other sexual and reproductive health care.  

State Efforts to Limit Harm to Medicaid Enrollees Who Receive Care at Planned Parenthood Health Centers 

Due to Planned Parenthood’s large role in providing family planning services to Medicaid enrollees, some states have committed to filling in gaps created by losses in federal revenues. In response to proposed budget cuts facing Planned Parenthood, eleven states (CA, CO, CT, IL, MA, ME, NJ, NM, NY, OR, WA) have allocated millions in funding to Planned Parenthoods to maintain access to care for their enrollees. All eleven of these states are also plaintiffs in a lawsuit challenging Section 71113. State responses have ranged from agreeing to cover the full cost of Medicaid services to allocating a specific amount of money for the year.  

California

On October 23, 2025, California Governor Newsom announced a plan to allocate over $140 million in state funds to assist Planned Parenthood health centers due to losses in federal funding caused by Section 71113. California has over 7 Planned Parenthood affiliates who maintain over 100 health centers. At California Planned Parenthoods, over 80% of patients rely on public health insurance such as Medi-Cal and the Family Planning, Access, Care and Treatment Program (FPACT). KFF estimates that in 2023, 47% of California female Medicaid recipients received who received their last contraceptive visit of 2023 went to a Planned Parenthood clinic for that care. On February 11, 2026, Governor Newsom signed legislation that allocates $90 million in the form of an emergency one-time grant to Planned Parenthood and other clinics providing reproductive health care services.   

Colorado 

In August 2025, Colorado Governor Polis signed legislation (Senate Bill 25B-2) which does not appropriate a specified dollar amount to Planned Parenthood but instead asserts that Colorado will reimburse an organization designated as a “prohibited entity” under the 2025 Federal Budget Reconciliation Law using state funds. This guarantees state funding for Planned Parenthood clinics in Colorado providing care to Medicaid enrollees without placing a specific dollar amount on the allocation. 

Connecticut  

On December 18, 2025, Governor Lamont announced an allocation of $8.5 million to Planned Parenthood of Southern New England to make up for lost federal reimbursement for the period that Section 71113 is in effect.  

Illinois

On December 23, 2025, the Illinois Department of Healthcare and Family Services announced a $4 million investment in Medicaid family planning services to offset the loss of federal Medicaid reimbursement for Planned Parenthood due to Section 71113. The Department estimates that Planned Parenthood received $4 million in federal Medicaid reimbursement in 2024 for services like contraception, sexual transmitted infection testing and treatment, cancer screenings, and other family planning services Illinoisans rely on.  

Massachusetts

 On July 24, 2025, Governor Healey announced a plan to provide $2 million in state funds to Planned Parenthood League of Massachusetts to support continued access to sexual and reproductive health including cancer screenings, contraception, and STI testing and treatment. These state funds are not sufficient to completely make up for the loss of federal funds. In 2023, Planned Parenthood League of Massachusetts received approximately $4.7 million in Medicaid payments in 2023, and the federal match in Massachusetts varies between 50% and 90% with a 90% match for family planning services. Massachusetts has not allocated any funds to Health Imperatives, another family planning provider in Massachusetts currently blocked from receiving federal Medicaid reimbursements. 

Maine

The Maine Legislature passed two bills ( LD 143, LD210), shortly before Section 71113 became effective, allocating over $6 million to family planning providers, including Planned Parenthood of Northern New England and Maine Family Planning. This funding was allocated to fill financial gaps these organizations face due to their ongoing provision of free and discounted reproductive health care. On January 27, 2026, Governor Mills proposed providing an additional $2.25 million in state supplemental funding to offset the impact of Section 71113 on Maine Family Planning and Planned Parenthood. The legislature will review the Governor’s proposed biennial budget, which requires approval in both the House and Senate.      

New Jersey 

In fiscal year 2023, the two Planned Parenthood affiliates in New Jersey collectively billed $6.9 million to New Jersey’s Medicaid program. The state paid $1.4 million of these claims and the federal government paid the remaining $5.4 million. On December 24, 2025, Governor Murphy announced an allocation of $8 million to reproductive health care providers who have been blocked from receiving federal Medicaid funds. The allocation will cover both the state and federal Medicaid reimbursements that the Planned Parenthood affiliates would have received if not for Section 71113.  

New Mexico

On October 3, 2035, New Mexico, Governor Grisham, signed emergency legislation that allocates $3 million to contract with Planned Parenthood for health services provided to Medicaid patients. Any unexpended balance remaining at the end of fiscal year 2026 will revert to the general fund.  

New York

On October 24, 2025, New York Governor Hochul announced that the state will cover any funding gap Planned Parenthood experiences due to Section 711113. The state has instructed Medicaid providers who would be considered “Prohibited Entities,” to continue to submit claims, and they will be paid with state only dollars. Planned Parenthood has five affiliates that operate 48 clinics in the state. 

Oregon 

In Oregon, Planned Parenthood of Columbia Willamette received over $15 million of state and federal Medicaid dollars in 2024. In November 2025, their legislature allocated $7.5 million to Planned Parenthood affiliates in an emergency session for this coming fiscal year while Section 71113 is in effect. 

Washington

Washington estimated that they paid over $23.8 million to Planned Parenthood in 2023 for services to Medicaid enrollees with $11.8 million of those funds coming from the federal government. On July 9, 2025, Governor Ferguson announced that the state would cover any gap in Medicaid funds Planned Parenthood experienced because they would no longer be eligible to receive funding from the federal government.  

Potential fraud in state Medicaid programs is getting renewed attention, with a recent emphasis on home care, also known as personal care or in-home supportive services. Home care helps with self-care activities such as bathing, dressing, and eating for older adults and people with disabilities. KFF estimates that over 5 million people use Medicaid home care, which allows individuals to receive long-term care without moving into an institution. The Trump administration has recently pointed to Medicaid home care as a source of fraud. Medicaid home care is susceptible to fraud because services are provided in people’s homes to vulnerable individuals who may be less able to advocate for themselves, including some with Alzheimer’s and other dementias. However, there are also additional safeguards against fraud in Medicaid home care compared to other types of Medicaid services. This issue brief describes how Medicaid home care operates, including who is eligible, the various systems in place to promote program integrity in its delivery, and challenges using data newly released by the Centers for Medicare and Medicaid Services (CMS). Key takeaways include the following.

• All states provide optional home care services to people whose needs are sufficient to warrant institutionalization. An institutional level of care is generally beyond what family members are capable of providing.
• Recognizing the higher risk of fraud in Medicaid home care, federal and state governments have implemented additional tools to identify and detect home care fraud. States, along with the federal government, use provider credentialing and enrollment and data analytics to help prevent fraud. There has been new attention on fraud in Minnesota’s Medicaid program recently, but the fraud, and the state’s work to root it out, date back at least 18 months. 
• On February 14, 2026, CMS released a dataset with provider-level spending data that the agency suggests could be used to identify unusual billing patterns for specific services, states, or providers, but the limited data could result in mistaken conclusions. Home care is a major emphasis of the new dataset, which stems from the fact that second to hospital spending, long-term care is the second-largest source of Medicaid spending. Although Medicaid long-term care was historically provided primarily in nursing facilities, most enrollees now recieve home care.

Why does Medicaid cover home care and who is eligible for services?

All states provide optional home care services. Under Medicaid, states are required to cover long-term care provided in nursing facilities, but not home care, which has been referred to as the “institutional bias” in Medicaid. States may only provide home care if they can demonstrate that providing the services would cost no more than institutional care would cost for an individual. All states choose to provide optional home care to people who would otherwise require institutionalization. The increased availability of home care reflects people’s preferences to remain in their homes. Expansions of Medicaid home care services also followed the 1999 Supreme Court ruling in Olmstead v. L.C., which declared that unjustified institutionalization of people with disabilities by a public entity (including Medicaid) is a form of discrimination and not permissible under the 1990 Americans with Disabilities Act. Even though nearly all of the benefits are optional for states to provide, the majority of people who use long-term care now do so at home.

Medicaid home care use is limited by eligibility criteria that generally make it only available to people whose needs are sufficient to warrant institutionalization. To be eligible for Medicaid home care, applicants must meet both financial and “functional” eligibility criteria. Functional eligibility for Medicaid home care, which is evaluated by assessment tools developed by states, generally requires individuals to demonstrate that they need an institutional level of care. There are no recent data available about states’ specific definitions for an institutional level of care, but it generally indicates that people would require 24-hour services and assistance with multiple activities of daily living (ADLs), which include bathing, dressing, eating, toileting, continence, and transferring between bed and other settings.

An institutional level of care is generally beyond what family members are capable of providing. People who require an institutional level of care generally have complex needs that require both skilled and unskilled services and often require services to be provided around the clock. In some cases, family caregivers may not have the medical expertise to provide services, but there are also challenges related to the physical demands of the job and having time to provide such intensive services. Helping family members to bathe, dress, and toilet themselves often requires the strength to lift them, which not all family members have. The time required to provide such intensive services also makes it difficult for family caregivers to provide this level of care and maintain employment or take care of their own health needs. KFF’s focus groups with paid and unpaid family caregivers provide detail that caregiving is physically, mentally, and emotionally challenging; and that family caregivers cannot provide an institutional level of care without supports. To help people requiring an institutional level of care remain at home, Medicaid supports family caregivers by providing supplemental paid care and with direct supports, such as respite care, training, and in some cases payments to the family caregivers to reflect the fact that caregiving makes it impossible to maintain outside employment.

What program integrity tools for Medicaid home care exist?

Recognizing the higher risk of fraud in Medicaid home care, federal and state governments have implemented additional tools to identify and detect home care fraud. In 2016, Congress passed the 21^st Century Cures Act, which requires states to implement electronic visit verification for all Medicaid personal care and home health services if a visit is made to a person in the home. State’s electronic visit verification must include six data elements: member receiving the services, caregiver providing the service, type of service, location of the service delivery, date of the service, and time the service begins and ends. Electronic visit verification was established to help promote fiscal integrity for Medicaid home care, and states had until 2023 to fully implement the requirements. The Health and Human Services Office of Inspector General (HHS OIG) has an active project underway to evaluate the availability and completeness of the electronic visit verification data and how states are using the data to promote program integrity.

An HHS OIG report finds that in fiscal year 2024, there were 298 fraud convictions “involving personal care service attendants” from the Medicaid fraud control units, which was 36% of all fraud convictions through the Medicaid fraud control unit, more than that of any other provider type. Although significant, the number of fraud convictions (total and as a percentage of all convictions) is notably lower than the average from 2015-2022 before electronic visit verification was fully in place. During the prior years, fraud convictions involving personal care service attendants averaged well over 400 each year and 43% of all convictions. The amount of money recovered from all convictions is small ($961 million in FY 2024 or $536 million on a 5-year average basis) relative to Medicaid spending.

States, along with the federal government, use provider credentialing and enrollment and data analytics to help prevent fraud. Providers must meet certain state and federal requirements to be eligible to participate in the Medicaid program. Additionally, states use data analytics to confirm that providers have not previously been convicted of committing Medicare fraud or fraud in a different state’s Medicaid program, and to identify unusual billing patterns for specific services or by specific providers. When Minnesota uncovered fraud in its Medicaid home care programs in 2024, the state undertook a series of actions to address that fraud, including targeting specific providers and specific types of services (Box 1).

What do newly released data about home care spending mean?

On February 14, 2026, CMS released a dataset with provider-level spending data that the agency suggests could be used to identify unusual billing patterns for specific services, states, or providers, but the limited data could result in mistaken conclusions. The data include seven fields, including the number of beneficiaries seen, counts of services, and the total spending for each procedure that is included in the data, but they omit significant elements important for pursuing meaningful analyses. With the data release, CMS posted figures to illustrate how the data could be used, with one of the figures displaying total spending among the top 20 procedures in the Medicaid data. The data show that personal care (the primary home care benefit) is the top procedure in terms of spending. However, the personal care “procedure” encompasses a wide range of services that may vary in complexity, difficulty, and length of visit (ranging from less than 30 minutes up to an entire day). In comparison, spending on emergency department visits is split among multiple procedure codes based on the complexity of the case and spending on psychotherapy is split based on the length of the visit (e.g., 30-minute visits and 45-minute visits are considered separate procedures). The data exclude all institutional records and all information about prescription drugs, which are significant shares of Medicaid spending, with hospital care accounting for 37% and being the single largest source of Medicaid spending.

Understanding the context for increases in home care spending is important context for interpreting spending data. Increased spending on Medicaid home care reflects state and federal policy choices to increase the availability of home care in lieu of institutional care when feasible. Analyses of federal spending on long-term care show that home care has grown from 1% of all long-term care spending in 1981 to 64% in 2023. Although the shift away from institutional care dates to the 1980s, the COVID-19 pandemic shone a new spotlight on the challenges of institutional care and illuminated the extent of unmet need for home care. In response, states expanded the availability of home care, increased payment rates for workers in home care settings, and made other efforts to help people remain at home rather than institutional settings. Between 2019 and 2023, the number of Medicaid home care users increased by over 750,000 people. In general, expansions of home care have garnered bipartisan support, with both 2024 presidential candidates expressing support for investments in family caregivers and more at-home services for people who need long-term care.

Since the opioid epidemic was declared a public health emergency in 2017, it has claimed more than half a million lives. While the epidemic was initially driven by prescription opioids and heroin, it has evolved in recent years, to be dominated by illicit synthetic fentanyl—a substance significantly more potent than morphine. By 2023, most counterfeit opioid pills contained a deadly dose. As of 2022, nearly 1 in 3 adults reported in a KFF survey that they or a family member have been addicted to opioids (29%).

Leading up to and during the pandemic, opioid overdose deaths increased sharply. Deaths began to fall in mid-2023 and have continued to decline, though they remain above pre-pandemic levels. While it is not possible to identify a single driver of the decline, multiple policy actions may have contributed. These policies included efforts to expand access to treatment and overdose-reversal drugs and public awareness efforts about counterfeit opioid pills. They also included supply-side actions aimed at improving fentanyl detection at the ports and borders and limiting the flow of precursor chemicals used to manufacture illicit fentanyl abroad. These efforts coincided with indicators of shifting fentanyl supply, including DEA testing that suggested lower fentanyl potency in counterfeit pills.

Despite progress, a range of more recent federal policy actions may affect future trends, including federal budget cuts, federal staffing reductions, and cuts to federal grants that support state and local programs; reduced Medicaid and Marketplace coverage; and a shift toward a more enforcement-focused approach, including the designation of illicit fentanyl as a “Weapon of Mass Destruction.” This analysis examines opioid overdose deaths over time – including 2024 (the latest finalized data available through CDC WONDER data) – and trends across demographic groups and states. Additional data can be found on KFF’s State Health Facts.

Key Takeaways:

Overall trends: Opioid overdose deaths fell sharply from 2023 to 2024 (79,358 to 54,045), driven largely by decreases in fentanyl-involved deaths. Even after these declines, deaths remained above 2019, the year before opioid deaths increased sharply during the pandemic.

Demographic variation: In 2024, opioid death rates were the highest among those aged 26-64, AIAN people, Black people, and males. All demographic groups saw declines in opioid death rates from 2023 to 2024. However, most groups still had higher rates in 2024 than in 2019.

State variation: State rates in 2024 ranged from 3.3 per 100,000 in Nebraska to 38.6 per 100,000 in West Virginia. From 2023 to 2024, opioid death rates fell across all states, with the largest drops in Virginia (-44%), Wisconsin (-44%), and West Virginia (-46%). About half of states remained above 2019 levels, which may reflect differences in the timing of fentanyl’s spread and state policy.

What are the trends in opioid deaths?

Opioid overdose deaths fell sharply in 2024, nearing pre-pandemic levels but remaining above 2019 (Figure 1). Total drug overdose deaths dropped from 105,007 in 2023 to 79,384 in 2024 (-24%), while opioid deaths fell from 79,358 to 54,045. Provisional CDC data suggest opioid deaths have continued to decline through 2025. By 2024, opioid deaths were near but still above pre-pandemic (2019) levels, about 4,200 higher than in 2019, the year before the sharp pandemic-era rise in opioid deaths.

Fentanyl was involved in most opioid overdose deaths in 2024 (Figure 1). Declines in fentanyl-involved deaths drove the overall drop in opioid deaths. Deaths involving other opioids, including prescription opioids and heroin, also declined but to a lesser extent. Opioid overdose deaths include fatalities of unintentional, intentional (suicide or homicide), and unknown intent. Any drug overdose death involving opioids is counted as an opioid overdose death. Because more than one opioid can be involved in a single death, opioid subcategories do not sum to total opioid deaths.

How do opioid deaths vary across demographics?

In 2024, opioid death rates were highest among adults ages 26 to 64, American Indian/Alaska Native (AIAN) people, Black people, and males (Figure 2). Rates were highest among adults ages 26 to 44 and 45 to 64 (29.1 and 24.9 per 100,000, respectively), well above other age groups. By race and ethnicity, AIAN people had the highest opioid death rate (35.5 per 100,000), and Black people had somewhat higher rates than White people (22.8 vs. 17.5 per 100,000), a reversal from earlier in the opioid epidemic when rates were higher among White people. Because White people make up a much larger share of the population, the number of deaths was highest among White people (33,105), followed by Black people (10,202) and AIAN people (845), even though rates were higher among Black and AIAN people. Opioid death rates among males were more than double those of females.

From 2023 to 2024, opioid overdose death rates declined across all demographic groups (Figure 3). Young adults (ages 18 to 25) saw the largest decline (-42%), while adults ages 65+, saw the smallest (-20%). Declines by race and ethnicity ranged from -28% among AIAN people to -39% among Black people, and rates fell for both males and females. 

Most demographic groups continued to have higher opioid death rates in 2024 than in 2019 (Figure 3). Rates remained especially elevated among AIAN people (+101%) and adults ages 65+ (+63%). Slower declines among older adults may reflect that SUD can be harder to detect and treat and that few treatment programs are tailored to older adults. Two groups had lower rates in 2024 than in 2019: White people (-9%) and young adults ages 18-25 (-30%). Declines among White people relative to other race and ethnicity groups may partly reflect better access to opioid use disorder treatment.

How do opioid deaths vary across states?

Opioid overdose death rates varied across states in 2024, ranging from 3.3 per 100,000 in Nebraska to 38.6 in West Virginia (Figure 4). Nebraska, South Dakota, and Iowa had the lowest opioid death rates, (3.3, 5.4, and 5.8 deaths per 100,000 people, respectively). Rates were the highest in the District of Columbia (34.1 per 100,000), Alaska (37.0), and West Virginia (38.6).

All states had declines in opioid overdose death rates from 2023 to 2024, but the size of the decline varied widely. Rates fell by 5% in South Dakota and 8% in Alaska, compared with larger drops of 44% in Wisconsin and Virginia and 46% in West Virginia (Figure 5). KFF State Health Facts provides opioid overdose rates by state for 1999-2024.

By 2024, about half of states continued to have opioid overdose rates above 2019 levels. Several states were close to pre-pandemic levels, including D.C. and Utah (+1%, +2%, respectively). Over one-third of states (39%) had rates that dipped below 2019 levels, with the largest declines in NJ (-42%), Ohio and Massachusetts (each -36%). Alaska and Oregon had the largest increases relative to 2019 (+239% and +226%) (Figure 5).

State differences in opioid-related policy and the timing of fentanyl spread may help explain variation in opioid overdose death trends. Differences in how states use state opioid response grants and settlement funds, and how states structure Medicaid coverage for substance use services, including whether they adopt federal opportunities to expand treatment access may affect outcomes. Fentanyl spread unevenly across states over time, generally moving from east to west. As a result, some states experienced earlier increases, often before the pandemic, while others saw their steepest growth later. These policy and timing differences can affect how states’ 2024 rates compare with 2019. 

From 2014 to 2024, over half a million lives (516,790) were lost to suicide, with 2022 marking the highest annual total on record. Since then, overall suicides have declined somewhat, but trends diverged by method: firearm suicides continued to rise, reaching a new high in 2024. As a result, firearms accounted for 57% of all suicides in 2024, up from 50% in 2014, while suicides by other methods fell. Some of the shift may also reflect undercounting if some suicides are recorded as unintentional drug overdose deaths. These shifts may have implications for prevention strategies including the capacity and design of crisis and treatment systems.

In July 2022, the 988 Suicide and Crisis Lifeline launched nationwide, replacing the prior 10-digit number with an easier to remember, three-digit option that connects people in distress to counselors at 200+ local crisis call centers and, when needed, other crisis services. Since launch through October 2025, 988 has received more than 19 million calls, texts, or chats nationally, alongside improved answer rates and shorter wait times.

The combination of 988, other benefit expansions and distance from the pandemic may be factors contributing to small declines in overall in suicides since the 2022 peak; however access to mental health and substance use disorder treatment gaps persist. In 2025, the Trump administration discontinued the LGBTQI+ 988 call line and advanced an array of federal policy actions that could limit access to care including projected coverage loss in Medicaid and the Marketplace.

Key takeaways from analysis of CDC WONDER data from 2014 to 2024, which represents the most recent and comprehensive data available include the following:

Overall death rate: The age-adjusted suicide death rate in 2024 was 13.7 per 100,000 people.

Overall trends: Suicide deaths fell slightly from their peak of 49,476 deaths in 2022 to 48,824 deaths in 2024, but trends by suicide method diverged: suicides by other means declined while firearm suicides reached their highest level and accounted for 57% of all suicides (up from 50% in 2014).

Demographic variation: In 2024, suicide death rates were highest among AIAN people and males (22.5 and 22.3 per 100,000, respectively). Over the past decade, rates increased the most for Black people, while rates were stable or declined somewhat for adults ages 45 to 64 and females.

State variation: State suicide death rates in 2024 ranged from 5.7 per 100,000 in Washington D.C. to 29.7 in Alaska. About four in ten states had stable or lower rates than in 2014, while rates increased in the remaining states, ranging from a 27% decrease in Washington D.C. to a 35% increase in Wyoming. Rates tended to be higher in many Western states, while lower rates were more common in parts of the Northeast and a few coastal states.

What are the trends in suicide deaths?

Firearm suicides reached their highest level in 2024, while suicides of other means decreased (Figure 1). Total suicide deaths peaked in 2022 and fell slightly by 2024 (about 600 fewer deaths). Even as overall suicides decreased, firearm suicides rose to their highest level in 2024, about 6,000 higher than in 2014, and accounted for 57% of all suicides in 2024 (up from 50% a decade ago). The increase has coincided with changes in gun ownership, including a surge in new buyers during the pandemic and greater racial and ethnic diversity among gun owners. Because firearms are highly lethal, greater access can reduce opportunities for intervention. Some state policies, including extreme risk protection orders (ERPOs) and other gun laws, have been linked to declines in firearm suicides.

How do suicide deaths vary across demographics?

Overall suicide death rates were highest among AIAN people and males in 2024 (Figure 2). AIAN people had the highest suicide death rate (22.5 per 100,000), higher than the rate among White people (17.2), while rates for other racial and ethnic groups were lower. Because White people make up a much larger share of the population, the total number of suicide deaths was higher among White people than AIAN people (36,560 vs. 545), even though AIAN people had a higher suicide death rate. While females are more likely to report mental illness and to attempt suicide, males had a suicide death rate about four times higher (22.3 versus 5.6 per 100,000). There are similar suicide rates across age groups in 2024 except that adolescent rates are lower (5.7 per 100,000) than other age groups.

Over the past decade, suicide death rates increased faster for younger than older adults and more for people of color than White people, while declining somewhat for adults ages 45 to 64 and females (Figure 3). From 2014 to 2024, rates increased 17% among adults ages 18 to 25 (from 13.4 to 15.7 per 100,000) and 13% among those ages 26 to 44 (from 15.9 to 18.0), while rates were mostly flat or declined among older age groups. Rates increased more among people of color than among White people, with the largest increase among Black people (up 53%, from 5.7 to 8.7), followed by Hispanic people (up 27%, from 6.3 to 8.0). In contrast, suicide rates among White people were more stable, rising 5% over the same period (from 16.4 to 17.2). Increasing suicide rates among people of color may reflect differences in diagnosis and access to mental health care, as well as stigma and discrimination. Trends may also be influenced by shifts in firearm access and potential racial and ethnic differences in 988 awareness, use, or perceived helpfulness.

How do suicide deaths vary across states?

Suicide death rates varied widely across states in 2024 (Figure 4). Rates ranged from 5.7 deaths per 100,000 people in the District of Columbia (D.C.) to 29.7 in Alaska, with a median death rate of 15.4 per 100,000. Rates tended to be higher in many Western states, while lower rates were more common in parts of the Northeast and a few coastal states. The suicide rate may vary by state due to factors such as demographics, firearm availability, mental health status, and access to mental health and crisis services.

About four in ten states had stable or lower suicide death rates than a decade ago, while suicide death rates increased in other states (Figure 5). Between 2014 and 2024, suicide death rates decreased or were relatively stable in 22 states. The largest declines were in D.C. (-27%, from 7.8 to 5.7 per 100,000), Vermont (-21%, from 18.7 to 14.7), and New Jersey (-19%, from 8.3 to 6.7). Rates increased by 15% or more in 10 states, with the largest increases in Wyoming (35% increase, from 20.6 to 27.8), Alaska (34% increase, from 22.1 to 29.7), and Iowa (33% increase, from 12.9 to 17.1).

Alcohol use disorder (AUD) is the most prevalent non-tobacco substance use disorder in the United States and over half of US adults (54%) say that someone in their family has struggled with an alcohol use disorder. Federal data show that 1 in 10 Americans (ages 12+) had an AUD in the past year and over 40% of drinkers reported binge drinking in the past month, yet only one-third of adults view alcohol addiction as a “crisis,” compared to over half who see opioids as such.

In early January 2026, the Department of Health and Human Services (HHS) released the updated 2025-2030 Dietary Guidelines for Americans (DGA). The report marks a departure from decades of guidelines that set recommendations to limit intake to specific daily caps (formerly one drink for women and two for men), instead advising people to “drink less for better overall health.” Without clear thresholds, it may be harder for individuals and clinicians to identify when clinical screening or treatment is warranted. This challenge is compounded by low public awareness of alcohol’s health risks. For example, fewer than 40% of US adults are aware that alcohol is a carcinogen, compared to over 90% awareness of tobacco’s link to cancer. In addition, clinical screening for AUD is inconsistent and treatment rates for AUDs are low. For those receiving or seeking treatment, a range of recent federal policy actions may affect future treatment access, including substantial coverage losses in Medicaid and Marketplace coverage.

This analysis largely focuses on the narrowest definition of alcohol deaths known as “alcohol-induced deaths” (referred to as “alcohol deaths” throughout the brief). These alcohol deaths are caused by conditions directly attributable to alcohol consumption, such as alcohol-associated liver diseases. Broader definitions of alcohol deaths extend this definition to also encompass cases where an alcohol-induced condition was a contributing factor, but not the underlying cause of death. Key takeaways from this analysis of CDC WONDER data from 2014 to 2024 include the following:

Key takeaways:

Overall trends: Alcohol deaths increased gradually before the pandemic, jumped in 2020 and 2021, and have fallen somewhat since then. Even after these declines, deaths remained above 2019, the year before the pandemic.

Demographic variation: In 2024, alcohol deaths were highest among adults ages 45 to 64, American Indian and Alaska Native (AIAN) people, and males. By 2024, alcohol death rates remained above 2019 levels for several groups; the groups most above their 2019 rates were adults ages 26 to 44, 65+, White people, and females.

State variation: State rates in 2024 ranged from 6.1 per 100,000 in New Jersey to 35.9 per 100,000 in New Mexico. In 2024, alcohol death rates remained higher than 2019 rates for most states. Changes ranged from declines in New Jersey (-9%) and West Virginia (-6%) to an 80% increase in Mississippi.

What are the trends in alcohol deaths?

Alcohol deaths are down from their peak but still above pre-pandemic levels (Figure 1). Alcohol deaths increased gradually before the pandemic, jumped in early pandemic years, and have declined somewhat since then. From 2014 to 2024, the year-over-year rise in alcohol deaths averaged about 5% per year, with the largest single-year jump from 2019 to 2020 (+26%). Deaths peaked in 2021 (54,258) and have fallen since. Even with declines after 2021, in 2024 alcohol deaths were still about 50% higher than a decade ago and about 20% higher than in 2019, the year before the pandemic.

How do alcohol death rates vary across demographics?

Alcohol deaths in 2024 were highest among adults ages 45 to 64, American Indian and Alaska Native (AIAN) people, and males (Figure 2). By age, alcohol death rates peaked among adults ages 45 to 64 (28.9 per 100,000) and were next highest among adults 65 and older (21.5 per 100,000). AIAN people had the highest alcohol death rate across all demographic groups (57.9 per 100,000), more than four times the rate among White people, the racial group with the next highest rate. Because White people make up a much larger share of the population, the total number of deaths was higher among White people (32,849 vs. 1,424), even though AIAN people had the higher death rate. Alcohol death rates among males (17.3 per 100,000) were more than double those among females.

Alcohol death rates remained above pre-pandemic (2019) levels in 2024, especially for adults ages 26-44, 65+, White people, and females (Figure 3). Rates increased gradually before the pandemic, rose sharply in 2020 and 2021, and then declined from their peak, but not enough to return to 2019 levels. Adults ages 26 to 44 had the largest continued increases, with 2024 rates 38% higher than in 2019. Adults ages 65 and older also remained elevated, with 2024 rates about 22% higher than in 2019. Rates among White people remained about 20% higher than pre-pandemic levels and higher than rates among other race and ethnicity groups. Female alcohol death rates were still about 20% above 2019 levels, while male rates were closer to pre-pandemic levels.

How do alcohol death rates vary across states?

Alcohol death rates varied widely across states in 2024 (Figure 4). Alcohol-induced death rates ranged from 6.1 per 100,000 in New Jersey to a 35.9 per 100,000 in New Mexico. Higher rates tended to be concentrated in the West, particularly in the Mountain West (and Alaska), while lower rates were more common across parts of the South and the Northeast. Many factors may contribute to the differences in alcohol mortality rates across states, some of which may include differences in alcohol consumption, cultural attitudes, state-specific alcohol policies, and treatment rates.

In 2024, alcohol death rates remained higher than pre-pandemic (2019) levels in most states, though the magnitude varied widely (Figure 5). Changes from 2019 to 2024 ranged from declines in New Jersey (-9%) and West Virginia (-6%) to large increases in Mississippi (+80%) and South Dakota (+63%). Leading up to the pandemic, most states had modest steady increases, though growth was faster in some more rural states, including Wyoming, Montana, Arkansas, and North Dakota. Consistent with national patterns described above, many states experienced their sharpest increases in 2020 and 2021 and then declined somewhat from their peak, but in most states, 2024 rates remained above 2019 levels. South Dakota and Mississippi saw especially large early-pandemic increases and only modest declines afterwards, leaving them with the largest percent increases in alcohol death rates from 2019 to 2024.

What factors may contribute to alcohol deaths?

Alcohol is linked to far more deaths when broader definitions are used (Figure 6). Many alcohol-related conditions develop over time, and alcohol can also worsen other health problems or contribute to injuries, which complicates how alcohol deaths are counted. This analysis uses a narrow definition, counting only deaths where alcohol is listed as the underlying cause on the death certificate, such as alcohol-related liver disease. When deaths are also counted where alcohol is listed as a contributing cause on the death certificate (“alcohol-related deaths”), the total number of deaths nearly doubles, reaching 93,118 in 2024 (Figure 5). Under this broader definition, alcohol-related deaths exceeded opioid overdose deaths (55,535 opioid deaths when underlying and contributing cause are included), and opioid deaths change little when moving from the narrow to broader definition (54,045 under the narrow definition). Others methods can produce even higher estimates of alcohol deaths by accounting for deaths that alcohol increases the risk of, even when alcohol is unlikely to be recorded on the death certificate, such as certain cancers.

Alcohol treatment rates are low, reflecting a mix of provider, patient, and financial barriers. In 2022, only 7.6% of people ages 12 and older with a past-year alcohol use disorder (AUD) received any treatment, and fewer (2.1%) received evidence-based AUD medication. Providers may lack confidence or knowledge in treating AUD and prescribing AUD medication, which can reduce treatment initiation or referrals. On the patient side, limited understanding of what constitutes problematic drinking and attitudes towards seeking treatment can hinder recognition of need for help. Among adults who meet the criteria for SUD—which may include symptoms like increased tolerance, repeated attempts to quit or control use, or social problems related to use–95% did not seek treatment and didn’t think they needed it. Even when people want care, practical constraints such as coverage limits, treatment availability, paid leave, and out-of-pocket costs can affect decisions about whether they start or stay in treatment.