Did the U.S. Spend Less Than Expected on Global Health in the First Year of the Trump Administration? The Complicated Answer

The short answer: Maybe. The long answer is...well, complicated.

The U.S. government's fiscal year 2025 ran from October 1, 2024, to September 30, 2025. Surely with the dismantling of USAID, and mass terminations of hundreds of projects, the US government must have spent much less on global health in FY25 compared to FY24, right?

You would think we could easily check receipts. But when we talk about how much the government spends, that includes three different, and often confusing, concepts.

What does "spending" actually mean in Washington D.C.?

The U.S. government uses specific terms for different stages of the money process.

Appropriations: the government's budget

This is the money Congress legally designates for a specific purpose, like global health. It is not just a notional ceiling; appropriations reflect what Congress has required agencies to spend for those purposes in that fiscal year. Global health money is appropriated mostly by two Congressional subcommittees:

• State, Foreign Operations, and Related Programs (SFOPS), which handles most foreign aid.

• Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS), which covers a relatively small amount of global health work like CDC's.

We know from the work of groups like KFF that Congress appropriated $12.37 billion for global health in FY2025. This is the most straightforward number for the public to track. But this is not how much the government spent on global health.

Obligations: the legal commitment

This is when a federal agency, after getting its funding appropriated and then "apportioned" by the Office of Management and Budget (OMB), use budget authority to enter into legally binding commitments through contracts, grants, or cooperative agreements to pay for goods or services.

Obligations are the most common indicator of "spending" used in official reports. It represents the commitment to spend the money.

Outlays: the money out the door

This is when the government actually writes the check (or, more often, makes an electronic transfer). Outlays—also called disbursements or expenditures—are the actual cash payments and often lag behind the obligation date, after the work is done or the services provided.

Obligations and outlays are complementary views of US government spending. It's true that obligations might never be fully disbursed for many legitimate reasons—the need or the project scope might change. And we know from 2025 that the U.S. can renege on promises. But one of the reasons it's important to monitor obligations is that appropriated funds have dates by which they must be obligated or expire. That's why you can see a rush of obligations by the end of the fiscal year when agency staff are making sure that money does not expire.

Let's look at obligations in the fiscal year 2025 and ask:

The FY25 puzzle: was less money obligated?

At the beginning of the Trump administration on January 20, 2025 (Q2 of FY2025), U.S. foreign assistance operations were disrupted by a series of extraordinary administrative actions. USAID was dismantled as an independent agency. Hundreds of active global health awards were terminated with little notice to implementing partners. These terminations occurred in multiple waves and affected programs that had already been legally awarded and were mid-implementation, creating immediate chaos across the globe.

The dashboard shows significant variation in obligations from year to year, but from FY24 to FY25, global health obligations decreased by 31.4%.

Figure 1. Global health obligations by fiscal year

Source: USAspending.gov

Why doesn't the money appropriated one year match the money obligated that same year? Due to delays in appropriation, it's practically impossible for much money to be obligated in the same year it is appropriated. Usually obligations start at the end of the first year or the beginning of the second.

Appropriated funds are allocated to be obligated within a set time frame, referred to as the "period of availability". That period of availability can be two years, five years (particularly for PEPFAR, the global HIV/AIDS program), or even longer.

In FY2020 and FY2021, Congress appropriated more funds for global health to respond to the global pandemic. That likely is part of the reason for increased obligations in FY2021 and FY2022. But since then appropriations for global health have been almost the same every year, between $12.2 and $12.9 billion dollars.

The danger of the 5-year expiration date

The good news: Our analysis shows no immediate evidence of any expired funds in FY25.

The potential bad news: The five-year period of availability funds, while designed to allow for complex, multi-year projects, can also hide a slowdown in spending.

Let's break down the FY24 and FY25 obligations by Treasury Account Symbol (TAS), which is the code Treasury uses to identify a specific federal account, including the agency responsible for the funds and how long the money is available to be spent.

Figure 2. FY2024 vs. FY2025 obligations by TAS duration.

Source: USAspending.gov

The drop in obligations is almost entirely driven by five-year accounts, suggesting that money in accounts close to expiring has been committed, while more funds in longer-duration accounts remain unobligated.

Many of these 5-year TAS are related to PEPFAR, so it's worth revisiting the impact of the disruptions caused by the dismantling of USAID. PEPFAR programs were affected differently than many non-HIV global health programs. While USAID-managed PEPFAR awards experienced significant terminations and reductions, CDC-managed PEPFAR programs were generally spared mass terminations. Instead, they faced substantial budget cuts and new operating constraints. In several countries where USAID PEPFAR programs were terminated and not restored, remaining CDC-funded programs absorbed cuts of 30 percent or more, resulting in sudden country-level budget reductions of 30–50 percent.

In other words, PEPFAR programs appear to have carried unusually large unobligated balances into the end of the fiscal year. And this is disturbing since PEPFAR and HIV/AIDS programs experienced fewer outright terminations than other technical areas (TB, malaria, etc.). Anecdotally, we have heard many stories about administrative paralysis, firings and shortages of key staff members, delays in award modifications, uncertainty driven by reorganizations at CDC and USAID, and more deliberate decisions by senior leadership to slow or withhold obligations. The obligation data alone cannot distinguish among these explanations.

What Comes Next

While we can't definitively say the US government spent less than it should have on global health—there doesn't seem to be any funds that expired—the drop in FY25 obligations is concerning. The long expiration date of some funds means a slowdown can be masked for years.

If an agency is slow to obligate global health funds (either through incompetence or maliciousness), many funds will not expire but remain un-obligated for another year, and another year after that, as long as the five-year period of availability is not up. This would be a "hidden" slowdown and completely legal. But over time, it would become obvious as the amount of un-obligated funds increased.

Additional budget reductions for PEPFAR HIV/AIDS programs have already been communicated for the first half of FY2026, raising the risk that under-obligation and delayed implementation will persist. Has global health program capacity been restored? We think that the opposite is more likely and that program capacity will continue to decline. But only time will tell. Trends in obligations—particularly for multi-year TAS—warrant close monitoring over the coming months.

With that grim warning, Congress should take steps to ensure global health funds are obligated in a timely manner and that agencies are not "kicking the can down the road" with the five-year expiry dates. The intent of yearly appropriations is to address global needs now, not later, and Congress should ensure that appropriated funds are obligated in a timely manner, by increasing the frequency of reporting on obligations and outlays, and by considering shortening the period of availability for global health funds, especially for PEPFAR.