Experiences with gun-related incidents are common across the country, with about one in five adults saying that they have personally been threatened with a gun (21%) or had a family member killed by a gun, including by suicide (19%), finds a new KFF survey about Americans’ experiences with gun-related violence and incidents. One in six (17%) say they personally witnessed someone being shot.

Smaller shares say that they have shot a gun in self-defense (4%) or personally been injured by one (4%). In all, slightly more than half (54%) of all adults say they have a connection to at least one of these gun-related incidents.  

Black adults (34%) are about twice as likely as White (17%) or Hispanic (18%) adults to say that they have a family member who was killed by a gun.  They are also about twice as likely as White adults to say they witnessed someone being shot (31% v. 14%), with Hispanic adults in between (22%).

Among the public overall, the vast majority say they worry at least “sometimes” that they or someone in their family will become a victim of gun violence. This includes small but important shares who say they worry about it “every day” (8%) or “almost every day” (10%).

About a third of both Hispanic (33%) and Black (32%) adults say they worry daily or almost daily that a family member will become a victim of gun violence, three times the share of White adults (10%). 

Parents of children under age 18 are more likely than other adults to say they worry daily or almost daily (24% v. 15%).

While most adults overall say they feel either “very” (41%) or “somewhat” (41%) safe from gun violence in their neighborhoods, significant shares say they feel “not too safe” (13%) or not safe at all (5%). One in six Black adults (17%) don’t feel at all safe in their neighborhoods, far greater than the share of White (2%) or Hispanic (9%) adults. 

About four in 10 adults (41%), and a similar share of parents with children at home (44%), say that they live in a household with guns. 

Among all adults with guns in their homes, three in four (75%) say that the guns are stored in ways that don’t reflect some common gun-safety practices.

Specifically, about half (52%) say that a gun in their home is stored in the same location as ammunition; more than four in 10 (44%) say that a gun is kept in an unlocked location; and more than third (36%) say that a gun is stored loaded.

Among parents in gun-owning households, about a third (32%) store a gun in an unlocked location, and the same share (32%) say a gun is stored loaded. Most (61%) store a gun in the same location as ammunition.

Small Shares Say Their Doctor or Child’s Pediatrician Talked to Them About Guns or Gun Safety

Amid a push for health professionals to treat gun safety as a public health issue, one in seven (14%) adults say that a health care provider has ever asked them if there were guns in their home, and 5% say that they talked about gun safety.

Among parents, a quarter (26%) say a pediatrician has ever asked them about guns in the home, and 8% say they talked about gun safety.Designed and analyzed by public opinion researchers at KFF, the survey was conducted from March 14-23, 2023, online and by telephone among a nationally representative sample of 1,271 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.

Introduction

Managed care is the dominant delivery system for Medicaid enrollees with 72% of Medicaid beneficiaries nationally enrolled in comprehensive managed care organizations (MCOs), accounting for 52% of total Medicaid spending (or more than $376 billion) in FY 2021. States pay MCOs on a capitated basis – that is, a fixed per member per month payment that must be “actuarially sound” when set. Capitation rates are typically established prospectively for a 12-month rating period, regardless of changes in health care costs or utilization.¹  However, as pandemic-related enrollment increases, utilization decreases, and other cost and acuity changes began to emerge, the Centers for Medicare & Medicaid Services (CMS) allowed states to modify managed care contracts and many states implemented COVID-19 related “risk corridors” (where states and health plans agree to share profit or losses), allowing for the recoupment of funds.

States and plans are now facing another period of heightened fiscal uncertainty due to the expiration of the continuous enrollment period (introduced at the start of the pandemic) on March 31, 2023. While millions could lose coverage during the unwinding – with some current enrollees no longer eligible, and others falling through the cracks due to renewal procedures — Medicaid MCOs may see overall average member acuity increase, since people who need more health care may be more likely to stay enrolled. This would result in higher per member utilization and costs. As they developed their 2023 MCO capitation rates, some states may have built in enrollment and acuity change assumptions related to unwinding, but considerable uncertainty remains.

This brief draws on data from KFF’s 22nd annual Medicaid budget survey to provide a high-level snapshot of states with minimum medical loss ratio (MLR) and remittance requirements and risk corridors (defined in Table 1 below) in place as of July 1, 2022 that may provide financial protection and limits on financial risk for states and plans as the unwinding unfolds. This brief also discusses states’ ability to amend capitation rates (during the rating period and retroactively) as the unwinding plays out.

Background

As of July 2022, 41 states, including DC, contract with comprehensive, risk-based managed care plans to provide care to at least some of their Medicaid beneficiaries. Medicaid managed care organizations provide comprehensive acute care (i.e., most physician and hospital services) and in some cases long-term services and supports to Medicaid beneficiaries. MCOs accept a set per member per month payment for these services and are at financial risk for the Medicaid services specified in their contracts. Under federal law, payments to Medicaid MCOs must be actuarially sound.^{2 , 3}  Actuarial soundness means that “the capitation rates are projected to provide for all reasonable, appropriate, and attainable costs that are required under the terms of the contract and for the operation of the managed care plan for the time period and the population covered under the terms of the contract.”

Unlike fee-for-service (FFS), capitation provides upfront fixed payments to plans for expected utilization of covered services, administrative costs, and profit. Plan rates are usually set for a 12-month rating period and must be reviewed and approved by CMS each year. States may use a variety of mechanisms to adjust plan risk, incentivize plan performance, and ensure payments are not too high or too low, including risk-sharing arrangements (including risk corridors), risk and acuity adjustments, medical loss ratios (MLRs, which reflect the proportion of total capitation payments received by an MCO spent on clinical services and quality improvement), or incentive and withhold arrangements.

In response to unanticipated COVID-19 costs and conditions that led to decreased utilization, CMS permitted states to make pandemic-related adjustments to managed care contracts and capitation rates to provide financial protection and limits on financial risk for states and plans. In 2021, more than half of MCO states reported implementing COVID-19-related risk corridors in their 2020 or 2021 contracts, and many states reported the recoupment of funds as a result. Since the start of the pandemic, Medicaid enrollment overall has grown substantially, resulting in increased MCO enrollment as well. Enrollment growth has been primarily attributed to the Families First Coronavirus Response Act (FFCRA) provision that required states to ensure continuous enrollment for Medicaid enrollees in exchange for a temporary increase in the Medicaid match rate.

The Consolidated Appropriations Act, 2023 ends the continuous enrollment provision and allows states to resume disenrollments starting April 1, 2023. States must initiate all renewals and other outstanding eligibility actions within 12 months. CMS has issued specific guidance allowing states to permit MCOs to update enrollee contact information and facilitate continued enrollment. The share of individuals disenrolled (and the pace of disenrollment) across states will vary due to differences in how states prioritize and process renewals. When states begin disenrollments, Medicaid managed care plans may see the acuity of their membership increase with implications for per member utilization and costs. In a recent KFF survey of non-profit safety net managed care plans, plans reported they expect the risk profile (or acuity) of members to increase (as a result of the unwinding), as plans anticipate “stayers” will be sicker than “leavers.” Plans also reported they expect MLRs to increase.

This brief describes minimum MLR and remittance requirements and risk corridors arrangements in place as of July 2022 that may provide financial protection and limits on financial risk for states and plans as another period of heightened uncertainty approaches. The brief also discusses states’ ability to amend previously certified and approved capitation rates already in place, including retroactive rate changes under certain circumstances. CMS requires states to document risk-sharing mechanisms (including MLR requirements and risk corridor arrangements) in health plan contracts and rate certification documents prior to the start of the rating period. States may be using a variety of other risk mitigation strategies and profit-sharing approaches, including profit caps, experience rebates, risk pools, reinsurance, and stop loss requirements, which are not covered in this issue brief.

Minimum Medical Loss Ratios (MLRs) and Remittance Requirements

WHAT ARE MLR AND REMITTANCE REQUIREMENTS?

The Medical Loss Ratio reflects the proportion of total capitation payments received by an MCO spent on clinical services and quality improvement, where the remainder goes to administrative costs and profits. To limit the amount that plans can spend on administration and keep as profit, CMS published a final rule in 2016 that requires states to develop capitation rates for Medicaid to achieve an MLR of at least 85% in the rate year.^{4 , 5}  Plans must calculate and report an MLR and submit an annual MLR report to the state (within 12 months after the end of the contract year).⁶  A review conducted in 2020 by the HHS Office of Inspector General found that while most plans submitted required annual MLR reports, almost half were incomplete, while over a third of states indicated that they did not review all MLR data for accuracy. States are required to submit a summary of plans’ MLR reports annually to CMS with their rate certification and, as of October 1, 2022, are required to use the standard reporting template released by CMS. States are also required to submit an Annual Managed Care Program report that must include financial performance information for each MCO, including MLR experience.

While there is no federal requirement for Medicaid plans to pay remittances to the state if they fail to meet the MLR standard, states have discretion to require remittances. (A state and the federal government share in any remittances in proportion to the state’s federal matching rate—if the state requires remittances). For a limited time (from federal fiscal years 2021 through 2023), The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act permits states to keep their regular state share of any remittances paid by Medicaid plans for expansion adults rather than only 10%.⁷  President Biden’s FY 2024 Budget proposes to require Medicaid managed care plans to meet an 85% minimum MLR and to require states to collect remittances if plans fail to meet the minimum MLR, estimating $20 billion in Medicaid savings over 10 years. Analysis of National Association of Insurance Commissioners (NAIC) data for the Medicaid managed care market show that average loss ratios in 2021 (in aggregate across plans) remained lower by three percentage points from 2019 (implying increased profitability).

WHAT ARE STATES DOING?

Nearly all MCO states reported a minimum MLR requirement is always in place for MCOs as of July 1, 2022 (Figure 1). While states must use plan reported MLR data to set future payment rates so that plans will “reasonably achieve” an MLR of at least 85%, states are not required to set a minimum MLR for their managed care plans. If states set a minimum MLR requirement, it must be at least 85%.⁸  Our findings represent a slight increase in the number of states that reported minimum MLR requirements compared to findings from OIG’s 2020 review. A few states noted that minimum MLRs may vary by program. Tennessee reported plans to implement a minimum MLR with remittance requirement in 2023 and Texas, a state with no state MLR requirement, reported an “experience rebate” requirement calculated on a graduated basis as a percentage of net income.

More than two-thirds of MCO states report they always require remittance payments when an MCO does not meet minimum MLR requirements (Figure 2). Twenty-eight states reported that they always require MCOs to pay remittances, while five states indicated they sometimes require MCOs to pay remittances (Figure 2). States reporting that they sometimes require remittances may limit this requirement to certain MCO contracts. For example, Utah limits its remittance requirements to MCO contracts for the adult expansion population. Seven states do not require remittances (including four states that do not set a minimum MLR requirement).⁹ 

Risk Corridors

Nearly half of responding MCO states reported risk corridors were always in place in MCO contracts as of July 1, 2022 (Figure 3). Risk corridors provide financial protection to MCOs and limits on financial risk to states. Risk corridors allow states and health plans to share profit or losses (at percentages specified in plan contracts) if aggregate spending falls above or below specified thresholds (“two-sided” risk corridor). Risk corridor thresholds may be tied to a target MLR. Risk corridors may cover all/most medical services (and members) under a contract or may be more narrowly defined, covering a subset of services or members. States may introduce risk corridors on a time-limited basis – for example, following the expansion of coverage to new groups (e.g., ACA Medicaid expansion adults). Massachusetts reported an overall market risk corridor in addition to individual plan risk corridors. CMS allowed states to retroactively implement risk mitigation strategies, including risk corridors, in response to unanticipated costs and decreased utilization related to the COVID-19 pandemic.^10 ,11  A few states reported implementing pandemic-related risk corridors beginning in 2020 but eliminated them in 2022 or 2023.

Rate Amendments

Even if the risk mitigation strategies described above are in place, states may determine rate amendments are necessary if their actual unwinding experience differs significantly from the assumptions used for the initial certified rates. During the rating period, states may increase or decrease rates by 1.5% per rate cell (which apply to population subgroups with one or more common characteristics such as age, gender, eligibility category, and geographic region) without seeking CMS approval for the change (different rules apply for states with approved rate ranges per cell).¹²  To make a larger change, the state must submit a rate amendment for federal approval that addresses and accounts for all differences from the most recently certified rates. A state may also determine that a retroactive adjustment to capitation rates (i.e., change to previously paid rates) is necessary. Retroactive adjustments are permissible under certain circumstances but must be certified by an actuary and approved by CMS. In the preamble to its 2020 final rule, CMS noted that states can adopt retroactive rate adjustments when substantial coverage changes occur mid-year or adjustments are necessary to address disease outbreaks, launches of high-cost prescription drugs, or other unforeseen circumstances that increase benefit costs.

Looking Ahead

In a dynamic environment where future MCO enrollment and utilization levels are uncertain, risk mitigation tools – like MLR and remittance requirements and risk corridors – can help states and MCOs plan for the unknown, ensuring greater fiscal certainty for both. With the Medicaid continuous coverage requirement ending this spring, another period of Medicaid enrollment and utilization uncertainty is beginning. While all states are now resuming Medicaid redeterminations or will soon, the pace and timing of those redeterminations will vary by state resulting in fiscal implications that are unique to each state. Risk mitigation strategies may provide financial protection and limits on financial risk for states and plans as the unwinding unfolds. In its 2022-2023 Medicaid Managed Care Rate Development Guide, released in April 2022, CMS recommended that all states “implement a 2-sided risk mitigation strategy for rating periods impacted by the public health emergency.”

As the process plays out in each state, more current data may help inform states whether mid-year rate amendments may be needed. State Medicaid programs use the most recent and accurate enrollment, cost, and utilization data available to ensure that MCO capitation rates are actuarially sound and that MCOs are not over-paid or under-paid for the services they deliver. In most states, Medicaid redeterminations will occur over 10-12 months that will cross more than one MCO contracting year (as most states contract on a state fiscal year or a calendar year basis) and while MCO membership losses will be immediately apparent, new utilization and acuity trends may take longer to discern. As they developed their 2023 MCO capitation rates, some states may have built in enrollment and acuity change assumptions related to unwinding (e.g., like in Arizona), but considerable uncertainty remains. Executives of publicly-traded companies that operate Medicaid MCOs (including Elevance¹³  and UnitedHealth Group¹⁴ ) have expressed confidence in states and their 2023 Medicaid rate-setting actions to date; however, MCOs will likely closely monitor utilization and acuity changes going forward. Sarah London, CEO of Centene, noted during the Q4 2022 earnings call: “We are focused on ensuring that state program rates reflect any shifting of the risk pool created by membership changes. We recognize the dynamics in each market are different, so we are leveraging our data to support early collaborative discussions with our state partners.”¹⁵ 

1. Medicaid and CHIP Payment And Access Commission, “Medicaid Managed Care Capitation Rate Setting,” March 2022; https://www.macpac.gov/wp-content/uploads/2022/03/Managed-care-capitation-issue-brief.pdf. ↩︎
2. These requirements apply to comprehensive risk-based plans as well as limited-benefit plans (e.g., those providing only dental or behavioral health services). ↩︎
3. The 2016 final rule on Medicaid managed care significantly strengthened the standards that states must meet in developing actuarially sound capitation rates and that CMS will apply in its review and approval of rates ↩︎
4. Julia Paradise and MaryBeth Musumeci, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions, (Washington, DC: KFF, June 9, 2016), https://modern.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/. ↩︎
5. The 85% minimum MLR is the same standard that applies to Medicare Advantage and private large group plans. ↩︎
6. Center for Medicare and Medicaid (CMS), “Medicaid Managed Care Regulations with July 1, 2017 Compliance Dates,” last updated June 30, 2017, https://www.medicaid.gov/federal-policy-guidance/downloads/cib063017.pdf. ↩︎
7. Center for Medicare and Medicaid (CMS), “Medicaid Managed Care Frequently Asked Questions (FAQs) – Medical Loss Ratio,” June 5, 2020, https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/cib060520_new.pdf. ↩︎
8. 42 CFR § 438.8(c). ↩︎
9. Georgia House Bill 1013, signed into law by Governor Kemp on April 4, 2022, establishes an MLR remittance requirement for MCOs effective for contract rating periods beginning on and after July 1, 2023. According to a 2021 Report by the HHS Office of Inspector General, Georgia did not have a state minimum MLR or remittance requirement in place as of September 2020. Further, rate certification reports reviewed for FY 2022 indicate that no MLR requirements were in place for FY 2022. (See:  Medicaid Rates for the Georgia Families and the Planning for Healthy Babies Program, July 1, 2021─June 30, 2022 Contract Period, Guidehouse for the State of Georgia Department of Community Health, April 1, 2021, and Medicaid Rates for the Georgia Families 360° Program, July 1, 2021─June 30, 2022 Contract Period, Guidehouse for the State of Georgia Department of Community Health, April 1, 2021, accessed at HMA Information Services.) ↩︎
10. Center for Medicare and Medicaid (CMS), “Medicaid Managed Care Options in Responding to COVID-19,” May 14, 2020, https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/cib051420.pdf. ↩︎
11. CMS, COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies (last updated June 30, 2020), https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf (pgs. 83-84 V.C.6). ↩︎
12. During the rating period, states may increase or decrease rates by a “de minimis amount” per rate cell. Federal regulations define the de minimis amount as 1.5% per rate cell (§438.7(c)(3)). If, however, the state initially elects to certify a rate range for a rate cell, the state is not permitted to use this de minimis change authority but may increase or decrease a capitation rate within a rate range by up to 1% during the rating period without submission of a new rate certification as long as the resulting rate does not fall outside of the 5 percent range limit allow by federal regulations (42 CFR §438.4(c)(2)(iii)). ↩︎
13. John Gallina, Executive Vice President and Chief Financial Officer of Elevance Health Inc., stated: “We’ve been working very closely with our state partners on Medicaid and feel very good about the rating actions.” ↩︎
14. Tim Spilker, CEO of UnitedHealthcare Community and State, indicated that states had taken redeterminations into account when setting rates for 2023 and further noted: “[R]evenue is in line with our expectations and consistent with the outlook that we shared in November. So, we’re appreciative of the balanced rational view that our states have taken as they’ve looked ahead, knowing that we’ve got many factors coming forward.” ↩︎
15. Centene Corporation 4th Quarter 2022 Earnings Call Transcript, February 7, 2023. ↩︎

On April 7, 2023, two conflicting rulings on the provision of mifepristone, the drug used for medication abortion, were issued by two separate federal court judges, one in Texas and one in Washington State. Judge Mathew Kacsmaryk, the judge in the US District Court for the Northern District of Texas Amarillo Division, issued a preliminary injunction in the case, Alliance for Hippocratic Medicine v. FDA, blocking the FDA’s approval of mifepristone dating back to 2000. The judge has stayed his decision for seven days to give the FDA time to appeal, but the ruling effectively impacts the entire nation and would effectively revoke the FDA approval granted to mifepristone in 2000.

On the same afternoon, Judge Thomas O. Rice from the United States District Court in the Eastern District of Washington ruled in a case that was filed by the Oregon and Washington Attorneys General joined by 16 other Attorneys General. The AGs are challenging the FDA’s decision to impose restrictions on prescribing and dispensing mifepristone through the Risk Evaluation and Mitigation System (REMS), claiming the restrictions on the dispensing of the drug imposed by the FDA are unnecessary and limit its availability. This ruling orders the FDA to maintain the current availability of mifepristone in the 17 states and DC, the plaintiffs in this case.

As a result, the FDA has conflicting orders: to suspend its approval mifepristone on one hand and not to alter its approval effective January 2023, on the other. Because these two federal court rulings conflict, the Supreme Court could be called upon to resolve this conflict and decide the merits of both cases. This Q&A summarizes some of the key issues related to these rulings.

Who are the plaintiffs that are suing to block medication abortion?

The plaintiffs in the Texas case, Alliance for Hippocratic Medicine (a newly formed anti-abortion advocacy coalition); the American Association of Pro-Life Obstetricians and Gynecologists; the American College of Pediatricians; and the Christian Medical and Dental Associations, as well as three individual doctors challenged the FDA’s approval of mifepristone, one of the drugs used in medication abortion. The plaintiffs are challenging the FDA’s approval process and subsequent modifications of the conditions for dispensing mifepristone (known as REMS) as being beyond the FDA’s authority. The plaintiffs also contend that an 1873 anti-obscenity law, the Comstock Act, prohibits the mailing of any medication used for abortion (for details on the case see: Legal Challenges to the FDA Approval of Medication Abortion Pills). The Judge’s ruling in this case directs the FDA to suspend its approval of the mifepristone while the litigation continues, but gives the FDA seven days to appeal the case to the 5th Circuit before the order takes effect. This ruling would block the sale and distribution of mifepristone in the entire country, and would also block access to the drug in states where abortion is legal and protected.

What is the lawsuit filed by Democratic State Attorneys General?

The Oregon and Washington Attorneys General joined by 16 other Attorneys General are also challenging the FDA’s decision-making about mifepristone, but rather than challenging the FDA approval process, the plaintiffs are calling into question the FDA’s decision to impose restrictions on prescribing and dispensing mifepristone through the Risk Evaluation and Mitigation System (REMS). As of January 3, 2023, mifepristone can only be prescribed by a certified provider and the drug can only be provided by a certified pharmacy or clinician. The judge in this case has issued a preliminary injunction blocking the FDA from changing any rules that would impact the availability of mifepristone in states bringing the lawsuit (WA, OR, CO, CT, IL, NV, AZ, RI, OR, DE, MI, NM, VT, HA, MD, ME, MN, PA, and DC).

What is medication abortion?

The most common medication abortion regimen in the United States involves the use of two different medications: mifepristone and misoprostol, which are FDA approved. Mifepristone, also known as the abortion pill, or RU-486 is sold under the brand name Mifeprex and through a generic manufactured by GenBioPro in the United States. The FDA has found that medication abortion is a safe and highly effective method of pregnancy termination. When taken up to 70 days of pregnancy, the medication abortion regimen successfully terminates the pregnancy 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.00064%). Mifepristone was first approved by the FDA in 2000, and by 2021, over half of abortions in the US were medication abortions. Despite being available for medication abortion for over two decades, there is still considerable confusion about the drug in this country. A KFF poll conducted in January 2023 found that about half of the public was unsure as to whether medication abortion is legal in their state, including four in ten (41%) women ages 18 to 49 and half of women living in states where abortion is legal.

A little-known fact is that mifepristone, under the brand name Korlym, was also FDA-approved in 2012 without any REMS to manage blood sugar levels (hyperglycemia) in adults with endogenous Cushing’s syndrome. Korlym is a higher dose of mifepristone than Mifeprex and is taken daily.

There is also a different medication abortion protocol using misoprostol alone that is more commonly used internationally. Misoprostol is frequently used in obstetrics and gynecology for procedures like the medical management of miscarriage, induction of labor, cervical ripening before surgical procedures, and the treatment of postpartum hemorrhage. While misoprostol is FDA approved for many medical uses, it has not been FDA approved for abortions, meaning it is used “off label” for this purpose in the US. The regimen is also recommended for up to 70 days (10 weeks) of pregnancy. Research has shown the misoprostol-only regimen to be a safe and highly effective method of pregnancy termination, however it may result in a higher incidence of side effects. Some U.S. telehealth organizations have been providing the misoprostol-only regimen as an option for medication abortion for several years.

Will medication abortion continue to be available?

It is too soon to tell what the impact will be on the availability of medication abortion. It’s not known how the FDA will act in response to the two conflicting rulings. The FDA approves drugs for the whole country and does not vary its approval by state. If the FDA is forced to suspend its approval of mifepristone, some clinics may respond to this ruling by switching from the mifepristone/misoprostol regimen to using a higher dose of misoprostol alone.

What is the next step in the litigation?

Hours after Judge Kacsmaryk’s ruling, the FDA filed a notice of appeal to the US Court of Appeals for the 5^th Circuit and Attorney General Merrick Garland said the government would request a stay to block this ruling while the appeal is considered. If the 5^th Circuit does not grant this request, the FDA is likely to appeal immediately to the Supreme Court of the United States to block the ruling during the appeal process. If the case is appealed but the courts do not provide a stay, then the distribution of mifepristone could be halted across the nation pending the final outcome of the case.

The FDA may not appeal Judge Rice’s decision as it directs the FDA to keep the status quo. The Attorneys General who brought the case may appeal the decision to the 9^th Circuit to seek an injunction to block the enforcement of the REMS approved in January 2023.

As both of these cases involve the FDA approval and provision of mifepristone, it is likely that if they reach the Supreme Court, it will review the cases together.

Are there other lawsuits that involve mifepristone?

Some are questioning how the new state authority to regulate or ban abortion intersects with the Federal FDA’s authority to regulate drugs. There are currently two cases in federal court challenging state abortion prohibitions and restrictions on federal preemption grounds. The maker of a generic mifepristone medication, GenBioPro, Inc., is challenging West Virginia’s total abortion ban, and an ob-gyn, Dr. Amy Bryant, is challenging the abortion restrictions in North Carolina, which include requirements that mifepristone be dispensed in person by a physician following a state-mandated counseling session and a 72-hour waiting period. In both cases, plaintiffs argue that the FDA’s authorization and regulation of mifepristone preempt state law banning the use of the medication or regulating its use more strictly, and given this, enforcement of the state laws should be blocked. If these lawsuits are successful, people living in states where abortion is banned could access medication abortion.

What impact do these rulings have on the FDA’s approval of other drugs?

These rulings will likely have implications far beyond abortion, though it is still too soon to tell. Court challenges such as these could open the door for other actors to potentially sue to block the approval of existing or new drugs that may be considered controversial, such as vaccines or treatments for conditions that are at the crosshairs of so-called “culture wars.” Manufacturers may be reluctant to bring to market certain new drugs or treatments if they are concerned that a court ruling could block their approval in the future.

Note: This post was updated on April 4, 2023, to include additional details and a table showing potentially affected preventive services.

On March 30, 2023, a judge in the U.S. District Court in the Northern District of Texas issued a final judgment in a court case challenging the provision of the Affordable Care Act (ACA) that requires most private health plans to cover a range of preventive services without any cost-sharing for their enrollees. Having concluded in September that aspects of the requirement were unconstitutional and violated religious rights, the judge’s remedy in the Braidwood Management v. Becerra imposes new limits on the government’s ability to enforce those requirements nationwide. This Q&A summarizes some of the key issues related to the ruling.

What does the ruling mean for the public?With about 100 million privately insured people using preventive services required by the ACA to be covered without out-of-pocket costs, the preventive services coverage requirement is the provision of the ACA that affects the broadest number of people, and it has been enormously popular with the public. Because of the ACA requirement, the vast majority of private health plans have to cover a range of preventive services and cannot impose deductibles or copays for them. If the ruling stands, over time, millions of people could end up paying more for preventive care and some may lose access to certain services. However, as sweeping as the ruling is, it does not completely and immediately wipe out preventive services coverage under the ACA.

That’s because the ruling applies specifically to services recommended by the US Preventive Services Taskforce (USPSTF) that were made after 2010 when the ACA was enacted. The ruling would not overturn coverage requirements for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), women’s preventive health services (such as contraception, well women care and prenatal care, breastfeeding support services, and intimate partner violence screening) recommended by the Health Resources and Services Administration (HRSA),  or services for children and young adults recommended by Bright Futures, though the plaintiffs had asked that those be struck down as well and that decision could be appealed. The ruling also only applies to updates to or new USPSTF recommendations issued since March 2010, when the ACA was enacted. It would effectively lock in place coverage requirements based on evidence from 13 years ago.

The ruling separately finds that the mandate to cover pre-exposure prophylaxis (PrEP), a medication taken to prevent HIV, violates the plaintiffs’ religious rights under the Religious Freedom Restoration Act (RFRA). While the RFRA remedy is limited specifically to the plaintiffs, because PrEP was recommended by the USPSTF after 2010, the medication and certain ancillary lab services can now be subject to out-of-pocket costs across all health plans and plans could elect to drop coverage altogether.

Coverage will not necessarily change immediately. Although the ruling is effective immediately, in many cases, health plan contracts are in place for the calendar year, and employers do not typically make changes to coverage or cost midyear. (It may be easier for plans to change formularies to allow for cost-sharing with respect to impacted drugs.)

Will cancer screenings be covered by insurance plans without out-of-pocket costs?

Screenings like mammography and cervical cancer screening would still be covered without out-of-pocket costs because they were recommended by the USPSTF prior to March 2010. Although colorectal cancer screening was included as a recommended service in 2010, it was limited to adults ages 50 to 75. In 2021, the USPSTF expanded their colorectal cancer screening recommendation to also include adults ages 45 to 49. Therefore, because of this ruling, people in their late 40s may begin to face cost barriers to colorectal screening. Similarly, lung cancer screening with low dose CT scans for adults aged 50 to 80 years with a 20 pack-year smoking history and currently smoke or have quit within the past 15 years was recommended in 2021 and could therefore be subject to out-of-pocket costs.

What are some examples of services that may now be subject to out-of-pocket costs?

Any service that was first recommended by USPSTF after March 2010 (and is not also recommended by another group like HRSA or ACIP) would no longer be required to be covered without out-of-pocket costs. For example, services and medications like statins to prevent heart disease, lung cancer screening, PrEP to prevent HIV, and medications to lower the risk of breast cancer (e.g., tamoxifen) for high-risk women may now be subject to copays, deductibles, or coinsurance.

Additionally, because some USPSTF recommendations that were in place before March 2010 have since been changed, there could be some groups of people who lose access to certain types of no-cost preventive care.  The USPSTF typically updates its recommendations every five years so that some of the recommendations could have changed slightly from the recommendation that was in place in 2010. This is the case with colorectal cancer screening discussed above and with HIV screening which was initially only recommended for high risk individuals and is now recommended for the general population.

Why were these preventive services originally included in the ACA?

One of the reasons this provision was included in the ACA was because research showed that cost-sharing, even in small amounts, reduces the likelihood that people use preventive services. Millions of people each year report delaying or forgoing needed health care due to costs.

The USPSTF is a group of independent experts that use a rigorous evidence-based process to review research, weighing both the benefits and risks of services. The group recommends services where there is sufficient evidence that the benefits of screening or other preventive care outweigh the risks associated with those interventions.

In the ACA, the preventive care coverage mandate was tied to recommendations by the USPSTF and other groups as a way of having a standard definition of what preventive care means, including changes over time as new evidence becomes available.

What is PrEP and how will the ruling affect access to it?PrEP is a medication that is 99% effective at preventing HIV through sex and at least 74% effective at prevention through injection drug use. Because of its effectiveness, PrEP has been a cornerstone of the federal plan to address HIV in the U.S.

While some health plans could opt to drop PrEP coverage altogether, we are more likely to see plans requiring copays, coinsurance, or deductibles. For generic PrEP, out-of-pocket costs might be nominal (the cash price for the drug is about $30 per month); for a brand name drug, particularly the new long acting injectable formation, cost-sharing could be substantial. For example, some enrollees could face a 20% or 50% cost in coinsurance for a $2,000 per month drug. Enrollees may also face cost-sharing for some of the ancillary care that is necessary for PrEP users, such as certain labs and provider visits. Before the ruling, these had been covered without cost-sharing following a 2021 clarification from the federal government that the PrEP recommendation encompassed those ancillary services.

Can states preserve coverage for these benefits?

There’s a long history of states regulating private insurance and mandating coverage of certain services, including some of these preventive services before the Affordable Care Act took effect. But there are real limits to what states can do—for example, they cannot regulate self-insured employer plans, which cover most people with private insurance, including 64% of people with employer-based coverage. So while states can, and are moving to, fill in some of the gaps that this ruling leaves, big gaps would likely remain.

Are these rulings final or will there be more legal action ahead?The Biden administration is appealing this ruling and will seek a stay of this remedy from the Fifth Circuit Court of Appeals. The Fifth Circuit may or may not issue that stay or do so in an expedient way, and the rulings could be appealed to the Supreme Court, specifically to what is known as the “shadow docket,” which means that the Supreme Court would review the issue of the stay, not the merits of the case as a whole. However, the merits of the case itself could eventually be reviewed by the Supreme Court.

What broader implications does this ruling have for the ACA?This is not the potentially fatal blow to the ACA like previous court cases, but it would limit a very popular benefit that millions of people use. For people who use preventive services, a key to access is what people have to pay out of their own pockets. Regardless of your plan, these ACA-required preventive services were covered without cost-sharing, meaning that the individual didn’t pay for the services. But if these rulings hold, individuals may have to pay something for the affected services as insurers review what is covered and by how much. This is the first time a court has ruled that the ACA preventive services coverage requirement other than the contraceptive coverage requirement violates employers’ religious rights. This has the potential to open the door to employers objecting to other services, such as vaccines.

Additional Resources:

Preventive Services Use Among People with Private Insurance Coverage

Explore an analysis of preventive services that finds roughly 100 million people received ACA-required preventive services with no patient cost-sharing in a typical year.

Explaining Litigation Challenging the ACA’s Preventive Services Requirements: Braidwood Management Inc. v. Becerra

Learn about the implications of the most recent legal challenge contesting the ACA requirement that most private insurance plans cover specific preventive care items and services at no cost to patients.

PrEP FAQs

Answer key questions about pre-exposure prophylaxis (PrEP) and its coverage, which prompted the court challenge.

Many Women Use Preventive Services, but Gaps in Awareness of Insurance Coverage Requirements Persist: Findings from the 2022 KFF Women’s Health Survey

Review findings on women’s receipt of cancer screenings and other preventive services as well as knowledge of insurance coverage requirements for these services.

Preventive Services Covered by Private Health Plans under the Affordable Care Act

Read a summary of the federal requirements for coverage for preventive services in private plans, major updates to the requirement, and recent policy activities.

Preventive Services Tracker

Explore the adult preventive services most private plans must cover, including a summary of the recommendation, the target population, and related federal coverage clarifications.

Note: To get the latest data on Medicaid enrollment, disenrollment, and procedural disenrollments, visit KFF’s Medicaid Enrollment and Unwinding Tracker. The analysis below uses CMS data about Medicaid and CHIP enrollment through December 2022, providing information about Medicaid enrollment levels during the pandemic.

This data note looks at national and state-by-state Medicaid and CHIP enrollment data through December 2022. After declines in enrollment from 2017 through 2019, preliminary data for December 2022 show that total Medicaid/CHIP enrollment grew to 92.3 million, an increase of 21.2 million from enrollment in February 2020 (29.8%), right before the pandemic and when enrollment began to steadily increase (Figure 1).¹  Increases in enrollment may reflect changes in the economy, changes in policy (like recent adoption of the Medicaid expansion in the Affordable Care Act), and the temporary continuous enrollment provision created by the Families First Coronavirus Response Act (FFCRA). Under the continuous enrollment provision, states generally cannot disenroll Medicaid enrollees while the provision is still in effect and in exchange, states receive a temporary increase in the federal Medicaid match rate. The continuous enrollment provision has halted churning in Medicaid – the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time – in addition to preventing Medicaid coverage loss during the pandemic. As part of the Consolidated Appropriations Act, signed into law in December 2022, Congress set an end to the continuous enrollment provision on March 31, 2023, and will phase down the enhanced federal Medicaid matching funds through December 2023. States that accept the enhanced federal funding can resume disenrollments beginning in April 2023 but must meet certain reporting and other requirements during the unwinding process. KFF estimates that Medicaid/CHIP enrollment will reach roughly 95 million enrollees in March 2023 before states may resume disenrollments during the “unwinding” of the continuous enrollment provision.

The information in this data note is based on KFF analysis of the Centers for Medicare and Medicaid Services (CMS) Performance Indicator Project Data. Medicaid/CHIP enrollment data are submitted monthly by state Medicaid agencies and, with each monthly update, states often revise the previous months’ enrollment to include retroactive enrollment and to better align with reporting criteria. Except for the latest month’s enrollment (December 2022), this brief reports data from the updated enrollment reports for all other months to reflect the most current enrollment data possible. However, the data presented in this brief will differ from those presented in monthly Medicaid and CHIP Enrollment Snapshots published by CMS, which use exclusively preliminary enrollment reports for all months.

Medicaid/CHIP enrollment increased following the implementation of the Affordable Care Act (ACA) but was declining in the two years prior to the pandemic. Following the implementation of the ACA Medicaid expansion to low-income adults in 2014, there were large increases in Medicaid and CHIP enrollment across states that followed steady growth in coverage of children over the past decade. These increases reflected enrollment among newly eligible adults in states that implemented the expansion as well as enrollment among previously eligible adults and children due to enhanced outreach and enrollment efforts and updated enrollment procedures tied to the ACA. This trend began reversing when enrollment started to decline in 2018 and continued to decline in 2019. Total enrollment fell from 73.3 million in December 2017 to 71.0 million in December 2019, a decline of 2.3 million people or 3.1%. Month-to-month enrollment declines slowed but continued until February 2020. The declines in enrollment, in part, reflected a robust economy, but experiences in some states suggested that they may have also reflected enrollment losses among people who were still eligible for coverage due to challenges completing enrollment or renewal processes.

Data show that Medicaid/CHIP enrollment is increasing amid the coronavirus pandemic, growing by 21.2 million enrollees or 29.8% from February 2020 to December 2022. Over this period, all states experienced total Medicaid/CHIP enrollment growth ranging from 18.1% to 80.6% (Figure 2).²  The state with the largest growth since February 2020, Oklahoma, implemented the Medicaid expansion on July 1, 2021. Four other states have implemented expansion since 2020 – Utah and Idaho in January 2020, Nebraska in October 2020, and Missouri (where the state began to process applications³  in October with coverage retroactive to 7/1/2021) – contributing to higher-than-average rates of enrollment growth in these states as well.

Virtually all growth was concentrated in Medicaid, which grew by 32.6% (21.0 million enrollees) from February 2020 to December 2022 data (Figure 3). Conversely, CHIP has seen less enrollment growth since February 2020 (3.1% or 211,000 enrollees) and several states (17) have seen declines in CHIP enrollment from February 2020 through December 2022 reports. These declines in CHIP enrollment for some states could reflect changes in family income, causing children to move from CHIP to Medicaid coverage. As discussed below, all states reported increases in child enrollment for Medicaid/CHIP overall during this time period.

Adult enrollment in Medicaid/CHIP has increased rapidly during the pandemic, growing by 41.5% from February 2020 through December 2022 enrollment reports (Figure 4). This growth amounts to an additional 14.2 million adults in the 49 states and DC that report adult/child monthly enrollment (Arizona does not report children or adults separately). As mentioned above, five states began newly enrolling expansion adults since January 2020 (Idaho, Missouri, Nebraska, Oklahoma, and Utah), contributing to increased adult enrollment. Child enrollment grew as well, but at a slower pace: 18.2% or 6.4 million enrollees in the same period. Still, every state reporting these data saw an increase in child Medicaid/CHIP enrollment from February 2020, despite declines in CHIP enrollment in some states (as discussed above).

Many could lose coverage as states resume disenrollments starting in April 2023, once the continuous enrollment provision expires. As part of the Consolidated Appropriations Act, signed into law in December 2022, Congress set an end to the continuous enrollment provision on March 31, 2023, allowing states to resume disenrollments in April 2023, though states must meet certain reporting and other requirements during the unwinding process. plan to take the full 12 to 14 months allowed by CMS for completing redeterminations and returning to normal operations, though some states will complete the process more quickly, with five states planning to take 9 to 12 months and one state planning to take less than 9 months (data are currently unavailable for two states, Ohio and Texas). During this time, millions could be disenrolled from Medicaid if they no longer qualify or if they face administrative barriers during renewal even if they continue to be eligible. How states manage the large volume of redeterminations during the “unwinding” of the continuous enrollment provision, as well as how states engage with enrollees and other stakeholders, will impact the continuity of coverage for millions of Medicaid enrollees.

1. Medicaid/CHIP enrollment reports are submitted monthly by state Medicaid agencies, reflecting enrollment on the last day of the month. With each update, states often revise data for the previous month(s) to better align with reporting criteria, such as including retroactive enrollment or other criteria. December 2022 data are preliminary and subject to change; all other months presented in this brief are based on updated enrollment reports. The data presented in this brief differ from those reported in monthly “Medicaid & CHIP Enrollment Snapshots” published by CMS, which use exclusively preliminary enrollment reports for all data reported. ↩︎
2. Although all states report an increase in Medicaid/CHIP enrollment from February 2020 through December 2022, some states have occasionally reported month-to-month decreases in their updated enrollment reports starting in late 2020 and into 2022 (AK, CT, DE, ID, IL, IN, KS, KY, LA, MT, NM, ND, PA, RI, UT, and WV). Generally, these month-to-month declines appear sporadic and so do not likely represent a trend. In July 2021, Kentucky’s total Medicaid/CHIP enrollment decreased by 6.7% and the state attributed the decrease to removing individuals who had been receiving temporary coverage under the state’s presumptive eligibility policy during the pandemic, according to the CMS Enrollment Snapshot for July 2021. Month-to-month decreases in Medicaid/CHIP enrollment generally represent data reporting issues that have not yet been resolved by states, or they may represent data reporting corrections where historical data has not yet been corrected. Nine states (AK, GA, IA, KS, MD, MO, MT, NJ, and ND) reported a decline in total Medicaid/CHIP enrollment from the updated November 2022 report to the preliminary December 2022 report. These declines were generally small and reflect preliminary enrollment data for December 2022, which is typically updated in subsequent enrollment reports as states update their enrollment counts (for example, to better capture retroactive enrollment or to better align with CMS’s reporting criteria). In many cases, updated reports show slight increases in enrollment from preliminary reports. ↩︎
3. Missouri has also expanded Medicaid since 2020. Medicaid coverage under expansion began when the state started processing applications in October 2021, with coverage retroactive to July 1, 2021, consistent with a state supreme court order. However, news reports indicate that the state was slow to process applications and enroll newly eligible expansion adults, although the state has worked with CMS to streamline the enrollment process and had made improvements in average application processing times as of September 2022. The state has still had higher-than-average enrollment increases from February even prior to implementing expansion. ↩︎

According to a new KFF survey with a nonprobability sample of clients from four online sources of contraception, one in four clients said they got emergency contraception to have on hand because of the Supreme Court’s decision to overturn Roe v. Wade. Additionally, more than a fifth (22%) said they have considered sterilization, 12% reported that they considered switching to or started using a more effective method of birth control, and eight percent said that they began to use birth control because of the Dobbs decision. These findings were consistent across states regardless of whether or not abortion was banned.

Respondents said they turned to telecontraception companies for birth control for various reasons, but the most frequently cited reason is that the birth control is delivered to their home (26%). Others noted privacy, difficulties getting appointments, and prior negative interactions with in-person care. Larger shares of LGBT+ individuals compared to non-LGBT+ cited a previous negative experience with an in-person provider as their main reason for getting their most recent birth control prescription online (11% vs. 7%).  Nearly one in five (18%) respondents cited the COVID-19 pandemic as the reason they first accessed birth control online.

These findings come from the KFF Survey of Online Contraception Clients, which was sent to active contraceptive clients over the age of 18 who had received contraception from their company in the past year (272,800 clients) by each of the four participating telecontraception companies. The survey was fielded from October 13 to December 8, 2022. A total of 5,925 telecontraception clients participated in the survey. This survey is based on a nonprobability sample and so its results are not generalizable to all telecontraception users. Learn more about who uses telecontraception and why in the brief, “Who Uses Telecontraception and Why? A Closer Look at Clients of Four Telecontraception Companies.”

Key Takeaways

• Based on the findings of a non-probability sample of 6,000 survey respondents from four telecontraception companies, the leading reason respondents cite for getting their most recent birth control via telecontraception is that it is delivered to their home (26%). Others cite privacy, difficulties getting appointments, and prior negative interactions with in-person care. Nearly one in five (18%) of respondents cited the COVID-19 pandemic as the reason they first accessed birth control online.
• The vast majority of respondents using telecontraception are women and two-thirds are 35 and younger, including larger shares who don’t have health insurance or who are LGBT+ compared to a nationally representative sample of contraceptive users in U.S. population.
• The most frequently received contraceptive method reported by telecontraception respondents is oral contraceptives (91%), followed by emergency contraceptive pills (9%). Nearly three in ten (29%) respondents overall say they purchased emergency contraception through an online company in the last 12 months.
• About three in four respondents with private insurance or Medicaid who tried to use their insurance for telecontraception paid nothing out-of-pocket for their birth control method. Half (51%) of those who did not use insurance paid between $31 and $50 and about a quarter (24%) paid over $50 for their birth control. The companies do charge a consultation or membership fee for all of their users and this cost is not covered by insurance.
• Four in ten (43%) respondents say they do not have a regular doctor and one in five (20%) have never had an in-person birth control visit.
• Almost a quarter (24%) of respondents report they have gotten emergency contraception to have on hand and over a fifth (22%) have considered sterilization in response to the Supreme Court’s decision to overturn Roe v Wade. These findings were fairly consistent across states regardless of whether abortion was banned or not.

Introduction

In recent years there has been increased interest in making contraception more accessible, particularly outside of traditional clinical settings. These efforts have gained urgency in wake of the Supreme Court decision in Dobbs v Jackson Women’s Health, which overturned Roe v. Wade, and the COVID-19 pandemic. However, even prior to both of these events, online companies had started to offer consumers the option of having contraceptives delivered to their home without needing to go for an in-person healthcare visit. While only a small share of people say they have used these online platforms, companies have reported a rapid growth in clients during the COVID-19 pandemic and an increase in emergency contraception orders since the Dobbs decision. There has been very little research to date on who uses telecontraception and why they choose to get their birth control online aside from a recent study focused on one online platform. In order to learn more about who is using telecontraception in the Fall of 2022, KFF conducted a survey of current clients from four telecontraception companies. The responses from individuals who responded to the survey across the four companies have been combined to give a snapshot of who is using telecontraception.

Methods

The KFF Survey of Online Contraception Clients was designed and analyzed by researchers at KFF. The survey was conducted via SurveyMonkey using a unique survey link that was sent to four telecontraception companies who then sent the link to their active contraceptive clients over the age of 18 who had received contraception from their company in the past year (272,800 clients). The survey was fielded from October 13 to December 8, 2022. A total of 5,925 telecontraception clients participated in the survey. Clients had an opportunity to be entered into a drawing for twelve $100 Amazon gift cards (three for each company) by submitting their email after completing the survey.

This survey is a non-probability sample based on telecontraception clients that responded to the survey from the four companies. There were not large differences in demographics and survey responses across the four companies surveyed, so the data for survey respondents from all four companies were combined to give an overall picture of telecontraception clients. These data were collected using a non-probability sampling frame, and the results are not necessarily representative of the broader population that receives online contraception.  However, the overall demographics of telecontraception clients from this sample closely matched a similar sample of women who said they have received a prescription or obtained a health care service from an online company in the prior 12 months obtained from KFF’s 2022 Women’s Health Survey, a nationally representative sample of women (See Appendix Table 1). Therefore, no additional adjustments, such as weighting, were made to the sample.

Demographics of Telecontraception Survey Respondents

This report presents a snapshot of telecontraception clients of four companies who responded to the KFF survey. The vast majority (97%) of responding telecontraception clients identify as women, while 2% are non-binary, 1% prefer not to say, and less than 1% identify as men, transgender or another gender. The four companies surveyed for this project do not offer male condoms, which explains why there are so few male clients in the sample.

Telecontraception clients responding to this survey ranged in age from 18-54. The largest share of those using telecontraception are between the ages of 26-35 (46%), about a third are ages 18-25 (32%), and over one in five are ages 36-54 (22%). Compared to females using short acting reversible contraception (such as the pill, injectables, patches or condoms, (SARC)) from the nationally representative KFF Women’s Health Survey, larger shares of telecontraception respondents fell in the 26-35 age range (46% vs. 35%) and smaller shares fell in the 36-54 age range (22% vs. 35%).

The majority of telecontraception survey respondents are White (66%), 17% are Hispanic, less than one in ten are Asian (9%), Black (8%), and American Indian/Alaska Native (1%). Larger shares of telecontraception respondents were White compared to those using SARC nationally (66% vs. 55%). Nearly two-thirds (65%) of telecontraception survey respondents earn more than $25,000 a year, while over one in four (27%) earn less than $25,000 a year, and another 9% prefer not to say (Figure 1).

Seven in ten respondents have private insurance (73%), about one in ten (9%) have Medicaid coverage, and almost one in five (19%) are uninsured. Compared to our nationally representative sample of SARC users, the share of those in the survey who have Medicaid coverage is smaller (9% vs. 20% nationally) and those who are without insurance is larger (19% in this survey vs. 9% nationally).

The largest share of respondents live in the South (40%), nearly a quarter are in the West (23%), one in five reside in the Midwest (20%), and 17% live in the Northeast United States, which is very similar to SARC users in our nationally representative sample (Appendix Table 1).

Nearly a quarter (23%) of respondents are LGBT+, three-quarters are non-LGBT+ (75%), and 3% prefer not to say. The share of respondents who are LGBT+ is slightly higher than the share of females who use SARC and identify as LGBT+ (23% vs. 17%).

Finally, a larger share of respondents are single, separated, widowed, or divorced compared to married or living with a partner (56% vs. 44%) and eight in ten have some college education compared to 15% with less than a college education (85% vs. 15%) (Table 1).  Smaller shares of SARC users nationally are single, separated, widowed or divorced (42% vs. 56%) and larger shares of telecontraception respondents have some college education compared to SARC users nationally (85% vs. 75%).

Experiences with Telecontraception

While telecontraception may be a new avenue for accessing contraception for many, nearly half (49%) of all telecontraception clients who responded to the survey say this is not the first time they have received their birth control from an online contraception company. Among those who have received birth control multiple times from an online contraception provider, the majority (86%) have been clients at the company for which they completed the survey for at least a year (Figure 3). The length of time people had been clients varied by company, with the majority of respondents at two of the companies saying they had been clients for at least a year (Company A = 85% and Company B = 95%), while about half of respondents at the other two companies say they have been clients for at least a year (Company C = 45% and Company D = 51%). All of the participating companies have been in business for a number of years.

One in five (20%) respondents say they have received birth control from at least one additional telecontraception company. This also differed by company, with Company A and Company B having smaller shares of respondents who have received birth control from a different online company (18% and 14%, respectively) compared to respondents at Company C and Company D (54% and 65%, respectively).

Many telecontraception companies utilize paid search engine marketing and social media to advertise and the majority of respondents say they first found out they could be prescribed birth control online through social media (59%), followed by Google search (19%), friends (9%), family (4%), and a healthcare provider (2%) (Figure 4).

Reasons for Accessing Birth Control Online

Although, telecontraception companies have reported they have seen a proliferation of clients due to the COVID-19 pandemic, most (82%) respondents say the pandemic was not the reason they accessed birth control online. Only one in five (18%) respondents say they first accessed birth control online because of the COVID-19 pandemic. Among those who first accessed birth control online because of the COVID-19 pandemic, the most widely cited reason was they could not get an in-person appointment (42%), followed by just over a quarter (27%) who were scared or nervous to go for in-person care, and 16% did not want to go to a pharmacy to pick-up their birth control prescription. A small share (5%) say they decided to start using birth control because of the pandemic and another one in ten cited another reason (Figure 5).

Among all respondents, the most frequent reason people cite for getting their most recent birth control via telecontraception is that the birth control is delivered to their home (26%). The second most frequent reason they say is they didn’t have insurance and couldn’t afford a doctor’s appointment (15%). Other reasons include not being able to get a doctor’s appointment (12%) or not having time for a doctor’s appointment (10%), as well as not wanting to interact with a provider (13%) or having a previous negative experience with an in-person provider (8%). Larger shares of LGBT+ individuals compared to non-LGBT+ cite a previous negative experience with an in-person provider as their main reason for getting their most recent birth control prescription via telecontraception (11% vs. 7%).

Among all respondents, smaller shares say the cost of birth control was more affordable (6%), they had privacy concerns (3%), a pharmacy is too far (1%), or they have always gotten birth control online (1%), and 5% cite some other reason (Figure 6).

Individuals accessing telecontraception can get new prescriptions for contraception via a telehealth visit (typically asynchronous) with an online provider or refill an existing prescription. The majority of respondents (66%) say they most recently refilled or renewed a birth control prescription they were already using. Just over one in five (21%) say they obtained a different brand of their previous birth control method, like an oral contraceptive brand, or possibly a generic. Only 7% of respondents say they received a new birth control method and another 7% say the prescription they most recently received was their first time ever using birth control.

Compared to respondents who had previously received birth control online, smaller shares of respondents receiving birth control for the first time from a telecontraception company say their most recent birth control method was a refill or renewal (52% vs. 79%). Larger shares of new telecontraception clients compared to returning clients say they got a different brand of their previous method (26% vs. 15%) or got a new birth control method (10% vs. 4%). Just over one in ten (11%) new telecontraception clients say this was their first time ever using birth control (Figure 7).

Contraceptive Methods Prescribed

Among respondents, the most frequently obtained contraceptive method is oral contraceptives (91%), followed by emergency contraceptive pills (9%) (Figure 8). Five percent of respondents received female condoms, 4% monthly contraceptive rings, 3% injectable contraception, 2% contraceptive patch, and 1% received the one-year ring, Annovera. One in ten (10%) respondents most recently obtained more than one contraceptive method and 95% of those who got more than one contraceptive method received emergency contraception and almost one third (31%) got female condoms. Female condoms and emergency contraception are often included as add-ons at the end of an order. Nearly three in ten (29%) respondents overall say they purchased emergency contraception through an online company in the last 12 months.

Cost and Coverage

Since 2012, the ACA’s contraceptive coverage requirement has required all new private plans to cover FDA-approved contraceptive methods for women without cost-sharing from a participating provider. For individuals with Medicaid coverage, family planning services have been a mandatory benefit category that all state programs must cover without any cost-sharing, but services must be obtained from a Medicaid-participating provider. One of the companies that participated in this survey does not accept Medicaid and the other three do, but do not accept Medicaid in all states.

When asked how much they had to pay out-of-pocket, including co-pays, for their most recent birth control prescription or product, the majority of respondents say they did not have to pay anything (55%). For those with some out-of-pocket costs, just over one in five (21%) paid $31-50, 9% paid more than $50, 8% paid $1-15, and 7% paid $16-30 (Figure 9). However, this varied significantly among those with some type of health insurance coverage and those without insurance (See Insurance Coverage of Telecontraception above). About three in four individuals with private insurance or Medicaid who tried to use their coverage paid nothing out-of-pocket for their birth control compared to only 6% of individuals without insurance who had no out-of-pocket costs. Some companies provide free birth control for women without insurance who are in financial need. The largest share of those without insurance (51%) paid $31-50 and about a quarter (24%) paid over $50 for their birth control prescription or product. Individuals without insurance could get free or low-cost birth control from a federally funded Title X clinic or federally qualified health center, however, they may choose to pay for telecontraception for other reasons like convenience.

Despite the requirement that most private insurance plans cover contraceptive services and supplies free of cost-sharing, there may be multiple reasons individuals with private insurance may have out-of-pocket costs. The telecontraception company may not have had a contract with their insurance plan, the telecontraception company could have been considered out of network, or the client might be enrolled in a plan that is exempt from the contraceptive coverage requirements, such as those that are grandfathered, or those with coverage through an employer that is exempt on religious grounds.

When asked about the last time they got a birth control method from a telecontraception company, the majority (87%) of insured respondents tried to use their insurance, while 13% did not (Figure 10). The top reason for not trying to use insurance was it was too complicated (18%). Another 16% of those who did not try to use their insurance say they did not know they could use their coverage. One in seven (14%) say the telecontraception company did not accept their insurance, while 12% did not try to use their insurance because they were concerned their parents or partner would see a charge for birth control. Seven percent say the brand of birth control they wanted was not covered by their insurance. Other reasons specified for not trying to use insurance included: the price was affordable without insurance, they hadn’t had a chance to update their insurance information, and they didn’t want their insurer to know about their birth control use.

For individuals who tried to use their insurance for their telecontraception prescription, one in five (21%) say their insurance imposed limitations on the number of months of birth control they could get, while the majority (55%) did not experience limitations (Figure 11). About a quarter of respondents who tried to use their insurance did not know if they experienced limitations on the number of months of birth control they could get. The share reporting that they experiencing limitation did not differ between those with private insurance or Medicaid (data not shown).

The largest share of respondents (65%) prescribed oral contraceptives say they receive three to five packs of pills at a time. While research has shown that best practice is to offer oral contraceptive users an extended supply of oral contraceptive pills such as a 12 month supply, few women receive a 12-month supply of contraceptives. Eight percent of respondents say they get 6 or more packs at a time, while 27% receive one to two packs at a time.

However, there are significant differences between those without insurance and those with Medicaid coverage compared to private insurance. Larger shares of respondents who used their Medicaid coverage (14%) or those that did not use insurance (13%) received six or more packs of pills compared to just 5% of those using private insurance (Figure 12). Currently, Medicaid programs in sixteen states and DC cover a 12-month supply of oral contraceptives at a time, which likely explains the larger share of individuals with Medicaid coverage receiving a 12-month supply. Some of the telecontraception companies also offer contraception at a discounted price if a larger number of packs at purchased at one time, which may be why a larger share of individuals without insurance received 6 or more packs. Twenty states and DC require state regulated insurers to cover an extended supply of contraceptives at one time, but this policy doesn’t include all plans (such as those that are self-funded) and there are still issues with implementation in getting insurance to cover more than 1 to 3 months of contraception at a time due to health plans’ concern over waste and increased costs.

Experiences Using Telecontraception

The telecontraception clients responding to this survey were largely satisfied with the services they received and felt that telecontraception made it easier for them to take and refill their birth control. Ninety-one percent of survey respondents report that getting their contraception through an online company has made it easier for them to take or get refills for their birth control, while only 1% report it has made it harder. Eight percent say there has been no change (Figure 13). Individuals that are able to continuously take and refill their birth control with little to no barriers are less likely to have an unwanted pregnancy.

The majority (98%) of respondents report they are satisfied with the birth control care they received from the telecontraception companies (Figure 14). Across the four companies, between 93% to 98% say they were satisfied with their care. Two percent of respondents report they are dissatisfied with the care they received, and 1% report they are neither satisfied nor dissatisfied.

Most respondents say they received enough information about different birth control methods from a medical provider at the company of their choice. Half (53%) report they got enough information, and another 43% report they received more than enough information. Only 4% report they did not get enough information—across companies, this share ranged from 4% to 11%. However, a higher share of respondents who were using a birth control method for the first time report they did not get enough information (8%) compared to those getting a different brand (5%), a new method (5%), or a refill (4%) (Figure 15).

Telecontraception clients generally receive birth control prescriptions by filling out a health questionnaire meant to screen for birth control contraindications, such as high blood pressure, smoking status, or a history of strokes. These questionnaires are then reviewed by healthcare providers, and depending on the policies of the state they reside in, the provider will communicate with the patient via text or chat or will have a video call with the patient to determine whether they are a good candidate for birth control and what method or brand they should use. Survey respondents were asked how they would prefer to engage with online medical providers when obtaining a new birth control prescription, and 57% prefer to message the online medical provider directly. Thirteen percent prefer video calls and 13% prefer phone calls. Sixty-six percent report they prefer filling out an online questionnaire that was reviewed by the medical provider. Four in ten (43%) would prefer to be able to engage with an online medical provider in more than one of these ways (Figure 16).

A somewhat higher share of Black respondents said they prefer to primarily engage with online medical providers via direct message compared to White respondents, and higher shares of Black, Hispanic and Asian respondents prefer to engage providers via video calls or phone calls. Somewhat higher shares of White respondents said they preferred to primarily engage with providers via a questionnaire (Table 2).

Overall, 14% of respondents report that they had had concerns or complications with a birth control method they had been prescribed through an online platform and wanted additional information or a follow with a medical provider (Figure 17). Among those who had concerns or complications, 72% report they were able to follow up with a provider at the company and another 20% say they never tried to follow up, and eight percent say they were not able to follow up. Larger shares of Asian respondents (20%) and respondents ages 18-25 (18%) report having a concern or complication with a birth control method prescribed through an online platform compared to White respondents (13%) and older respondents (10% of those over age 36) (Table 3). Additionally, larger shares of those getting birth control for the first time or getting a new method or different brand say they had concerns or complications with their method compared to those getting a refill or renewal.

Connections to the Health Care System

For some, interacting with a telecontraception provider may be their only interaction with a health care provider, while others may use telecontraception for a convenient way to get birth control, but have other connections to the health care system through a brick-and-mortar clinic. Over half (55%) of respondents report they have a regular doctor or health care provider they usually see when they are sick or need routine care. Four in ten (43%) say they do not have a regular doctor, and another 3% say they were not sure. The share without a regular doctor is much higher than women overall in the U.S. (43% vs. 18%). Larger shares of younger respondents compared to older and LGBT+ individuals compared to non-LGBT+ do not have a regular doctor or health care provider. Nearly seven in ten respondents without insurance say they do not have a regular health care provider. Larger shares of Black respondents compared to White respondents and respondents in the Northeastern part of the U.S. compared to all other regions of the country say they have a regular doctor.

Regular check-ups give patients the opportunity to talk with their health care providers about a broad range of issues, such as preventive health services, role of lifestyle factors on health, and management of chronic health issues. Fifty-two percent of respondents say they have received an in-person annual wellness exam or check up in the past twelve months, while 46% have not. Among those who have a regular doctor or health care provider, 70% report they received an in-person annual exam or check-up in the past 12 months compared to just 30% of those without a regular doctor or health care provider (Figure 18 and Table 4).

Eighty percent of respondents say they have had had an in-person birth control care visit where a doctor or health care provider had talked to them about their different birth control options at some point in their lives. Among this group, 17% say their last in-person visit was in the past year and 31% say it was one to two years ago. Another 35% report their last visit was in the last three to five years, and 16% say it was more than five years (Figure 19).

One in five (20%) telecontraception respondents report they have never had an in-person birth control visit (Figure 20). Higher shares of respondents ages 18-25 (36%), respondents who identify as LGBT+ (24%), those with Medicaid coverage (22%), and those who are uninsured (24%) report they had never had an in-person visit compared to respondents ages 26–35 and 36–49, those who identify as non-LGBT+, and those with private insurance. Over a third (32%) of Asian respondents and 28% of Hispanic respondents also say they have never had an in-person birth control visit, compared to 22% of Black respondents and 16% of White respondents.

Post-Roe Actions

On June 24, 2022 the Supreme Court issued their decision in Dobbs vs Jackson Women’s Health, and overturned Roe v Wade, which eliminated the federal constitutional standard that had protected the right to abortion. Now states can set their own policies banning or protecting abortion rights. As of April 2023, 13 states have banned abortion. After the Dobbs decision, telecontraception companies reported an influx of emergency contraception orders.

In response to the ruling, almost a quarter (24%) of respondents report that they have gotten emergency contraception to have on hand and over a fifth (22%) have considered sterilization. Twelve percent report that they have considered switching to or have started a more effective method of birth control, and eight percent have started using birth control due to the Dobbs decision (Figure 21).  These findings were fairly consistent across states regardless of whether abortion was banned or not.

There were some differences in these contraceptive considerations or actions by certain subgroups like race/ethnicity, income, insurance type, and sexual orientation (Table 5). Smaller shares of Black and Hispanic respondents (14% and 21%) compared to White respondents (26%) say they had considered sterilization in the wake of the Dobbs decision, but larger shares of Black and Hispanic respondents say they started birth control (15% and 12%) compared to White respondents (7%). Larger shares of those with lower incomes compared to higher incomes (14% vs. 6%) and those with Medicaid coverage or those without insurance (14% and 11% vs. 7%) compared to those with private insurance say they started birth control. A larger share of LGBT+ individuals compared to non-LGBT+ individuals say they got emergency contraception to have on hand (33% vs. 23%), considered sterilization (43% vs. 17%), and considered switching to or starting a more effective birth control method (20% vs. 10%) after Roe v Wade was overturned.

Looking Forward

While telecontraception remains a relatively new avenue for accessing contraception and only a small share of people say they have accessed services through these platforms, it has been difficult to know the characteristics of telecontraception users and what their experience has been like. Those who responded to this survey are generally satisfied with their experience, say telecontraception has made it easier for them to get their birth control, and they appear to be getting enough information about different birth control methods. However, this is a limited convenience sample and may not be representative of the larger population of telecontraception clients. Telecontraception has provided a way for people to get their birth control without having to leave their home, which has been helpful for many during the COVID-19 pandemic. However, some are left paying out-of-pocket, especially those without insurance, for birth control methods that would otherwise be covered free of charge at a federally funded clinic or through their insurance. In addition, all users must pay a membership or consultation fee, even though their insurance or Medicaid would cover the full cost of a visit and supply if they went to an in-network provider. Many of those accessing contraception online do not have a regular doctor or have never had an in-person birth control visit, so this may be the only information they are getting about birth control methods. Because there are a limited number of birth control methods for them to choose from, telecontraception may not be a good fit for those wanting long-acting reversible contraceptive methods or more comprehensive contraceptive counseling.  However, for those who use reversible hormonal methods or seek emergency contraceptive pills, telecontraception offers privacy and convenience, which is valued by the respondents of this survey.

As reproductive health policies and abortion access becomes more restrictive in some states, online companies may play a greater role in expanding access to sexual and reproductive health care.

Medicare is a primary source of health insurance coverage for several million people younger than age sixty-five who have long-term disabilities.

Published in the journal Health Affairs, this analysis compared measures of access to care, cost concerns, and satisfaction with care for beneficiaries younger than age sixty-five versus those ages sixty-five and older, using the 2019 Medicare Current Beneficiary Survey. It also compared beneficiaries in traditional Medicare with those in Medicare Advantage, given that a growing share of younger beneficiaries with disabilities are enrolled in private plans.

It finds that Medicare beneficiaries younger than age sixty-five reported worse access to care, more cost concerns, and lower satisfaction with care than beneficiaries ages sixty-five and older, regardless of their type of Medicare coverage. Among beneficiaries younger than age sixty-five in traditional Medicare, the share reporting cost concerns was highest among those without supplemental coverage.