Implications of Continuous Eligibility Policies for Children’s Medicaid Enrollment Churn

Authors: Elizabeth Williams, Bradley Corallo, Jennifer Tolbert, Alice Burns, and Robin Rudowitz

Published: Dec 21, 2022

Summary and Key Takeaways

Provisions in an omnibus spending bill currently under consideration in Congress would require all states to adopt continuous eligibility for children in both Medicaid and the Children’s Health Insurance Program (CHIP) and would decouple the Medicaid continuous enrollment requirement from the public health emergency (PHE). States currently have the option to provide 12 months of continuous coverage for children in Medicaid and/or separate CHIP, and about half of states do so for all children in Medicaid. Although states may only renew coverage for children once per year, children may lose coverage before the renewal period on account of changes in circumstances or administrative procedures such as data checks. Current continuous eligibility policies for children in Medicaid allow a child to remain enrolled for a specific period of time unless the child ages out of coverage, moves out of state, voluntarily withdraws, or, in some cases, does not make premium payments. KFF analysis of the Centers for Medicare and Medicaid Services (CMS) Performance Indicator Project Data finds 37.8 million children were enrolled in Medicaid (including Medicaid expansion CHIP) as of August 2022, with about half of those children in states with 12-month continuous eligibility and about half in states without the policy.

This analysis uses Medicaid claims data to follow a cohort of children newly enrolled in Medicaid in July 2017 in states with and without 12-month continuous eligibility to examine how children’s enrollment in Medicaid changes over time and understand the effect of continuous eligibility policies. Key findings include the following:

The disenrollment rate was lower for children in states with 12-month continuous eligibility policies in the period before annual renewals. The percentage of children who disenrolled and then re-enrolled within the year (or “churned” in and out of Medicaid) was also lower in states with 12-month continuous eligibility (2.9%) compared to states without the policy (5.3%).
Following annual renewals, the cumulative disenrollment more than doubled – some of which is to be expected, with family income changes – but cumulative churn also more than doubled from 4.0% in month 12 to 10.5% in month 15, signaling many eligible children are losing coverage at their annual renewal. Churn and disenrollment rates increased sharply in states with and without 12-month continuous eligibility following annual renewal, though increases were larger in states without 12-month continuous eligibility.
While churn rates increased among all racial/ethnic groups following annual renewal, the increase was largest for Hispanic children, growing from 5.2% in month 12 to 12.5% in month 15.

Our findings indicate that 12-month continuous eligibility policies are effective tools to reduce Medicaid disenrollment and churn rates within the year. However, some children may still lose coverage at annual renewal regardless of state adoption of 12-month continuous eligibility, and multi-year continuous eligibility policies could help children maintain coverage beyond one year and keep children from losing coverage during the renewal process. These findings are particularly relevant to the current policy landscape with provisions in the omnibus spending bill. In addition, following approval in Oregon, other states are seeking waivers to provide Medicaid continuous eligibility for multiple years, especially for young children. Lastly, all states will be required to conduct renewals for all individuals on Medicaid when the Medicaid continuous enrollment requirement ends, and an estimated 5.3 million children could lose Medicaid/CHIP coverage during the unwinding period.

What is continuous eligibility?

Under current law states are required to renew coverage for most children in Medicaid and CHIP no more than once every 12 months, but children may lose coverage before the renewal period under certain circumstances. Even with an annual renewal process, states can redetermine eligibility due to a change in circumstance (such as an increase in family income) at any point during the year, and some states conduct data matches on a periodic basis to identify changes in circumstances between annual renewal periods. Children may be disenrolled at annual renewal for a variety of reasons, including because they are no longer eligible for the program or they experience barriers navigating the redetermination process despite remaining eligible. Children can also voluntarily withdraw at any point (often when they have another source of coverage).

Under current law, states have the option to provide 12-months of continuous coverage for children in Medicaid and/or separate CHIP. Continuous eligibility policies for children in Medicaid allow a child to remain enrolled for a specific period of time even if there are fluctuations in income. Continuous eligibility would not apply if a child ages out of coverage, moves out of state, voluntarily withdraws, or, in some cases, does not make premium payments, and children in states with 12-month continuous eligibility are still subjected to annual renewals. As of January 2022, 24 states provided 12-month continuous eligibility for all children in Medicaid, and KFF analysis of CMS Performance Indicator Project Data finds, among all children in Medicaid (including Medicaid expansion CHIP) as of August 2022, 19.3 million (or 51% of) children were in states with 12-month continuously eligibility and 18.5 million (or 49% of) children were in states without the policy.¹

The Families First Coronavirus Response Act (FFCRA) requires states to provide continuous Medicaid enrollment in exchange for enhanced federal matching funds during the pandemic. Under FFCRA, the continuous enrollment requirement is in effect through the end of the month in which the PHE ends. During this time, states have not been able to disenroll people from Medicaid; however, when the continuous enrollment requirement ends, all Medicaid enrollees will undergo the renewal process, and millions of people, including children, could lose coverage if they are no longer eligible or face administrative barriers during the process despite remaining eligible. The current PHE is in effect until January 11, 2023, and the Biden administration has said it will give states a 60-day notice before ending the PHE. Since that notice was not issued in November 2022, it is expected the PHE will be extended again.

Provisions in an omnibus spending bill currently under consideration in Congress would require all states to adopt continuous eligibility for children in both Medicaid and CHIP and would decouple the Medicaid continuous enrollment requirement from the PHE. Under this legislation, all states would be required to implement 12-months continuous eligibility for children beginning on January 1, 2024. In addition, the bill would terminate the Medicaid continuous enrollment requirement on March 31, 2023, and permit states to resume disenrollments beginning in April 2023. Enhanced federal funding would continue to be available to states that comply with requirements for redeterminations during the transition period, though the enhanced funding would phase down through December 2023.

Continuous eligibility policies have been shown to lower rates of churn. Churn occurs when individuals temporarily lose Medicaid coverage and disenroll and then re-enroll within a short period of time. Churn in Medicaid suggests that some children are disenrolled due to short-term changes in income or circumstances that made them temporarily ineligible or are disenrolled for procedural reasons because they were unable to complete the redetermination process. When individuals churn on and off coverage, they experience gaps in coverage that could limit access to care and lead to delays in getting needed care. Gaps in coverage can be especially problematic for young children who are recommended to receive frequent screenings and check-ups.

Oregon was the first state to receive waiver approval to implement continuous coverage for children beyond 12-months. To extend continuous eligibility for children for multiple years or for adults for 12 months or longer, states must use the Section 1115 waiver process. Oregon received approval of a Section 1115 waiver application in September 2022 to provide continuous eligibility for children in Medicaid from birth until age six as well as two years of continuous eligibility for all enrollees age six and older. Other states have proposals in development or pending CMS approval.

What is the effect of 12-month continuous eligibility?

Disenrollment rates were lower for children in states with 12-month continuous eligibility policies. In the months leading up to annual renewal, the percentage of children who were disenrolled was lower in states with 12-month continuous eligibility compared to states without. By month 12, the cumulative disenrollment rate was 9.9% in states with 12-month continuous eligibility compared to 14.0% in states without the policy (Figure 1). The percentage of children who disenrolled and then re-enrolled in Medicaid within a short time period (or “churned” in and out of Medicaid) was also lower in states with 12-month continuous eligibility policies. Among all children, in states with continuous eligibility, 2.9% churned compared with 5.3% in states without continuous eligibility (Figure 3). There may be other policy differences between states with and without continuous eligibility that also contribute to the variation in disenrollment and churns rates, but these are outside the scope of this analysis.

Cumulative Percent of Children Disenrolled from Medicaid in Each Month Following Initial Enrollment in States With and Without 12-Month Continuous Eligibility (CE) for Children

What happens to disenrollment and churn after 12-month renewals?

Among all states, the disenrollment rate more than doubled following annual renewal. The cumulative disenrollment rate increased from 11.8% in month 12 (prior to completion of the annual redetermination) to 29.2% in month 15 (after the annual redetermination was completed), a 17.4 percentage point increase (Figure 2). Children can be disenrolled at annual renewal for a number of reasons, including because they are no longer eligible for the program or they experience barriers navigating the redetermination process despite remaining eligible. While disenrollment rates increased in both states with and without 12-month continuous eligibility after month 12, disenrollment rates remained lower in states with 12-month continuous eligibility. This could be due to another period of 12-month continuous eligibility beginning as well as other differences in enrollment practices between states with and without continuous eligibility.

Cumulative Percent of Children Disenrolled from Medicaid in Each Month Following Initial Enrollment

The churn rate also more than doubled following annual renewal, suggesting many children may be disenrolled due to administrative barriers at their annual renewal. The cumulative churn rate increased from 4.0% in month 12 to 10.5% in month 15 (Figure 3). Churn rates sharply increased after month 12 for states with 12-month continuous eligibility and states without; however, the increase was smaller for states with 12-month continuous eligibility (5.2 percentage points) compared to those without (7.9 percentage points). High rates of churn indicate that children are losing coverage for procedural reasons or because of temporary fluctuations in income.

Cumulative Churn Rates Before and After Annual Renewal in States With and Without Continuous Eligibility for Children

While churn rates increased among all racial/ethnic groups following annual renewal, the increase was largest for Hispanic children. This suggests Hispanic children may be more likely to experience income volatility or be disenrolled for procedural reasons at annual renewal compared to children of other races (Figure 4). Even before annual renewals at month 12, Hispanic children had slightly higher cumulative churn (5.2%) compared to other groups, but the gap widened following annual renewal.

Cumulative Churn Rates Before and After Annual Renewal, by Race/Ethnicity

Excluding infants, churn rates were similar across age groups before renewal at month 12, and all age groups experienced a similar increase in churn following annual renewal. Infants had the lowest cumulative churn rate at month 12 (2.2%), but experienced a sharp increase following annual renewal, reaching 9.8% by month 15, which is similar to the cumulative churn rates for the other age groups (Figure 4).

Looking Ahead

12-month continuous eligibility policies are effective tools to reduce Medicaid disenrollment and churn rates within the year. This analysis confirms what other analyses have found and demonstrates state adoption of 12-month continuous eligibility can decrease churn within the year, reducing the impact of income volatility on families and limiting the share of eligible children disenrolled due to procedural issues. National churn rates could be reduced further if legislation currently being considered in Congress passes (as it is expected to) and the policy is required for all states. While this analysis cannot determine whether children no longer enrolled in Medicaid had another source of insurance coverage, it is likely that 12-month continuous eligibility would reduce the number of children who are uninsured. That would come with higher federal and state Medicaid spending.

Multi-year continuous eligibility policies could help children maintain coverage beyond one year and keep children from losing coverage during the renewal process. This analysis finds churn increases during annual renewal periods, indicating children may be losing coverage at that point for procedural reasons regardless of state 12-month continuous eligibility policy status. Recently, some states have taken action to extend continuous eligibility for children in Medicaid for multiple years. While Oregon was the first state to submit and receive approval to extend continuous eligibility for children in Medicaid from birth until age six, Washington has also submitted a waiver renewal application, which is still pending CMS approval. In addition, New Mexico recently closed their public comment period on a similar waiver renewal application, and California is expected to follow.

A multi-year continuous eligibility policy could also be a tool to reduce disparities in churn rates and promote health equity. This analysis found Hispanic children experienced the largest increase in churn following annual renewals. A multi-year continuous eligibility policy, like the one included in Oregon’s recent waiver approval, would keep children from birth to age six continuously enrolled and reduce the number of children disenrolled for procedural reasons or temporary income fluctuations at annual renewal. States are especially targeting infancy and early childhood for continuous eligibility policies because the first years of life are an important developmental period for children when they are recommended to receive frequent screenings and check-ups.

Our findings indicate disenrollment and churn rates for children increase substantially following annual renewal, which could have implications for the end of the PHE. A report from the Assistant Secretary for Planning and Evaluation (ASPE) estimated 5.3 million children would lose Medicaid/CHIP coverage when the PHE ends; of those expected to lose coverage, an estimated 72% are likely still eligible for Medicaid/CHIP. Further, some groups may be more at risk of losing coverage at the end of the PHE. Our findings indicate Hispanic children may be more likely to lose coverage at renewal for procedural reasons, and a previous KFF analysis found individuals with limited English proficiency were more likely to experience administrative barriers when completing Medicaid renewal processes. Efforts to conduct outreach and provide enrollment assistance can help ensure that those who remain eligible for Medicaid are able to retain coverage and those who are no longer eligible can transition to other sources of coverage.

Methods

Data Source & State Exclusion Criteria

KFF used the Transformed Medicaid Statistical Information System (T-MSIS) 2017-2019 Demographic Eligibility Base File and Dates Files (Release 1). We used BENE_ID to link files when available and, when BENE_ID was missing, we used MSIS_ID to link files (see the TMSIS User Guide for information on linking variables). We used the longitudinal files to track enrollment outcomes among children from July 2017 through December 2019.

We use 44 states in our main analysis and 30 states for analyses using race/ethnicity. We excluded states due to missing or inconsistent data based on state-level information available from the DQ Atlas (Appendix Table 1).

Enrollee Sample Selection

Our sample is comprised of a cohort of children who “newly enrolled” in Medicaid or Medicaid Expansion Children’s Health Programs (MCHIP) in July 2017 with full benefits for that month. We defined newly enrolled as those who were not enrolled in Medicaid for the four months prior to July 2017 and were continuously enrolled for the first four months, through October 31, 2017. The four-month minimum enrollment period excludes children who were enrolled under presumptive eligibility provisions, but never completed an application or were determined to be ineligible. We excluded children enrolled in separate CHIP programs (SCHIP) because some states provide continuous eligibility for Medicaid but not for SCHIP. We excluded children born before January 1, 2001 because they would have turned 19 during the study period and children’s continuous eligibility provisions generally extend through age 18. We also excluded children eligible through a medically needy pathway in July 2017 because continuous eligibility provisions generally would not apply to this group. Finally, we excluded children who died during the study period. Our final sample includes 419,888 Medicaid enrollees in our main analysis (of 44 states) and 267,382 enrollees in our race/ethnicity analysis (30 states).

Calculating Enrollment, Disenrollment, and Churn

To calculate enrollment patterns, we used the DE Dates file’s start and end dates on enrollment spans. Short enrollment gaps of 28 days or less can represent data reporting errors, so we merged the spans on either side of the gap into a single, continuous enrollment span. Nearly all enrollment spans in the TMSIS data begin on the first day of the month and end on the last day of the month, but there are some rare cases in which disenrollments fall in between the first and last day of the month. For people in those situations, we considered them enrolled for the month if they had at least 15 days of coverage. We calculated disenrollment rates as the percentage of children from the initial cohort who had disenrolled in a given month. We defined churn as people who disenrolled and re-enrolled within 365 days. The renewal process varies by state and can take up to 60 days to process; this analysis compares churn rates at month 12 (prior to completion of the annual redetermination) to month 15 (after the annual redetermination was completed) to capture the effect of annual renewals. When calculating disenrollment and churn, we did not account for changes in eligibility group or benefit levels (i.e., from full benefits to restricted benefits) during the study period.

The Centers for Medicare and Medicaid Services (CMS) Performance Indicator Project Data reports total child enrollment in Medicaid and CHIP (Note: Arizona does not report children or adults separately and is not included in totals). To estimate Medicaid (including Medicaid expansion CHIP) enrollment only, we estimate the share of children in S-CHIP alone in each state using the CY 2019 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF). We calculate and subtract the number of children in S-CHIP from the PI data total child enrollment in August 2022. Then, we sum the Medicaid enrollment for all states with 12-month continuous eligibility in Medicaid and states without the policy. ↩︎

Global Health Funding in the FY 2023 Omnibus

Published: Dec 20, 2022

Updated on January 3, 2023

The FY 2023 Omnibus appropriations bill and accompanying reports, released by Congress on December 20, 2022, and signed by the President on December 29, 2022, includes funding for U.S. global health programs at the State Department, U.S. Agency for International Development (USAID), Centers for Disease Control and Prevention (CDC), and National Institutes of Health (NIH).[i] Funding provided to the State Department and USAID through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totals $10.6 billion, an increase of $731 million above the FY 2022 enacted level and $15 million below the FY 2023 request. The bill provides higher levels of funding for almost all program areas compared to the FY 2022 enacted level, with the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and global health security receiving the largest increases; funding for bilateral HIV and family planning and reproductive health (FPRH) remained flat. Funding for global health provided to the CDC totals $693 million, an increase of $46 million compared to the FY22 enacted level, but $55 million below the FY23 request. Funding for the Fogarty International Center (FIC) at the NIH totaled $95 million, $8 million above the FY22 enacted level and essentially flat compared to the FY23 request. See the table below for additional detail on global health funding in the FY 2023 omnibus (downloadable table here). See the KFF budget tracker for details on historical annual appropriations, including Senate and House amounts, for global health programs.

Table

KFF Analysis of Global Health Funding in the FY23 Omnibus

Department / Agency / Area	FY22Finalⁱ (millions)	FY23 Request (millions)	FY23 Omnibusⁱ (millions)	Difference: FY23 Omnibus – FY22 Final	Difference: FY23 Omnibus – FY23 Request
State, Foreign Operations, and Related Programs (SFOPs) — Global Health
HIV/AIDSⁱⁱ	–	$4,700.0	–	–	–
State Department	$4,390.0	$4,370.0	$4,395.0	$5 (0.1%)	$25 (0.6%)
USAID	$330.0	$330.0	$330.0	$0 (0%)	$0 (0%)
of which Microbicides	$45.0	$45.0	$45.0	$0(0%)	$0(0%)
ESF Account	Not specified	$0.5	Not specified	–	–
Global Fund	$1,560.0	$2,000.0	$2,000.0	$440 (28.2%)	$0 (0%)
Tuberculosisⁱⁱ	–	$352.0	–	–	–
Global Health Programs (GHP) account	$371.1	$350.0	$394.5	$23.5 (6.3%)	$44.5 (12.7%)
Economic Support Fund (ESF) account	Not specified	$2.0	Not specified	–	–
Malaria	$775.0	$780.0	$795.0	$20 (2.6%)	$15 (1.9%)
Maternal & Child Health (MCH)ⁱⁱ	–	$1,044.0	–	–	–
GHP account	$890.0	$879.5	$910.0	$20 (2.2%)	$30.5 (3.5%)
of which Gavi	$290.0	$290.0	$290.0	$0 (0%)	$0 (0%)
of which Polio	$75.0	Not specified	$85.0	$10 (13.3%)	–
UNICEFⁱⁱⁱ	$139.0	$135.5	$142.0	$3 (2.2%)	$6.5 (4.8%)
ESF account	Not specified	$29.0	Not specified	–	–
of which Polio	Not specified	$0.0	Not specified	–	–
Nutritionⁱⁱ	–	$161.0	–	–	–
GHP account	$155.0	$150.0	$160.0	$5 ( 3.2%)	$10 (6.7%)
ESF account	Not specified	$10.3	Not specified	–	–
AEECA account	Not specified	$0.8	Not specified	–	–
Family Planning & Reproductive Health (FP/RH)^iv	$607.5	$653.0	$607.5	$0 (0%)	$-45.5 (-7%)
Bilateral FP/RH^iv	$575.0	$597.0	$575.0	$0 (0%)	$-22 (-3.7%)
GHP account^iv	$524.0	$572.0	$524.0	$0 (0%)	$-48.1 (-8.4%)
ESF account^iv	$51.1	$25.0	$51.1	$0 (0%)	$26.1 (104.2%)
UNFPA^v	$32.5	$56.0	$32.5	$0 (0%)	$-23.5 (-42%)
Vulnerable Children	$27.5	$25.0	$30.0	$2.5 (9.1%)	$5 (20%)
Neglected Tropical Diseases (NTDs)	$107.5	$114.5	$114.5	$7 (6.5%)	$0 (0%)
Global Health Securityⁱⁱ	–	$1,003.8	–	–	–
USAID GHP account^vi	$700.0	$745.0	$900.0	$200 (28.6%)	$155 (20.8%)
of which for the Coalition for Epidemic Preparedness Innovations (CEPI)	–	–	$100.0	–	–
State GHP account^vii	Not specified	$250.0	Not specified	–	–
ESF account	Not specified	$6.0	Not specified	–	–
AEECA account	Not specified	$2.8	Not specified	–	–
Emergency Reserve Fund	^viii	^ix	^x	–	–
Health Resilience Fund^xi	–	$10.0	–	–	–
Health Reserve Fund^xii	–	–	$8.0	–	–
SFOPs Total (GHP account only)^xiii	$9,830.0	$10,576.0	$10,561.0	$731 (7.4%)	$-15 (-0.1%)
Labor Health & Human Services (Labor HHS)
Centers for Disease Control & Prevention (CDC) – Total Global Health	$646.8	$747.8	$692.8	$46 (7.1%)	$-55 (-7.4%)
Global HIV/AIDS	$128.9	$128.4	$128.9	$0 (0%)	$0.5 (0.4%)
Global Tuberculosis	$9.7	$9.2	$11.7	$2 (20.6%)	$2.5 (27.1%)
Global Immunization	$228.0	$226.0	$230.0	$2 (0.9%)	$4 (1.8%)
Polio	$178.0	$176.0	$180.0	$2 (1.1%)	$4 (2.3%)
Other Global Vaccines/Measles	$50.0	$50.0	$50.0	$0 (0%)	$0 (0%)
Parasitic Diseases	$27.0	$31.0	$29.0	$2 (7.4%)	$-2 (-6.5%)
Global Public Health Protection	$253.2	$353.2	$293.2	$40 (15.8%)	$-60 (-17%)
Global Disease Detection and Emergency Response	Not specified	Not specified	Not specified	–	–
of which Global Health Security (GHS)	Not specified	Not specified	Not specified	–	–
Global Public Health Capacity Development	Not specified	Not specified	Not specified	–	–
National Institutes of Health (NIH) – Total Global Health	$954.0	–	–	–	–
HIV/AIDS	$628.1	$614.8	Not specified	–	–
Malaria	$239.0	Not specified	Not specified	–	–
Fogarty International Center (FIC)	$86.9	$95.8	$95.2	$8.3 (9.5%)	$-0.6 (-0.7%)
Labor HHS Total	$1,600.8	Not yet known	Not yet known	–	–

Notes:
i — The FY22 Final bill includes a provision giving the Secretary of State the ability to transfer up to $200,000,000 from the ‘Global Health Programs’, ‘Development Assistance’, ‘International Disaster Assistance’, ‘Complex Crises Fund’, ‘Economic Support Fund’, ‘Democracy Fund’, ‘Assistance for Europe, Eurasia and Central Asia’, ‘Migration and Refugee Assistance’, and ‘Millennium Challenge Corporation’ accounts “to respond to a Public Health Emergency of International Concern.”
ii — Some HIV, tuberculosis, MCH, nutrition funding, and global health security funding is provided under the ESF and AEECA accounts, which is not earmarked by Congress in the annual appropriations bills and is determined at the agency level.
iii — UNICEF funding in the FY22 Final bill includes an earmark of $5 million for programs addressing female genital mutilation.
iv — The FY22 Final and FY23 Omnibus bills state that “not less than $575,000,000 should be made available for family planning/reproductive health.”
v — The FY22 Final and FY23 Omnibus bills state that if this funding is not provided to UNFPA it “shall be transferred to the ‘Global Health Programs’ account and shall be made available for family planning, maternal, and reproductive health activities.”
vi — According to the Department of State, Foreign Operations, and Related Programs FY23 Congressional Budget Justification, $250 million of this funding is “for contributions to support multilateral initiatives leading the global COVID response through the Act-Accelerator platform.”
vii — According to the Department of State, Foreign Operations, and Related Programs FY23 Congressional Budget Justification, this funding is “to support a new health security financing mechanism, being developed alongside U.S. partners and allies, to ensure global readiness to respond to the next outbreak.”
viii — The FY22 Final bill states that “up to $100,000,000 of the funds made available under the heading ‘Global Health Programs’ may be made available for the Emergency Reserve Fund.”
ix — The FY23 Request states that “this request includes $90.0 million in non-expiring funds to replenish the Emergency Reserve Fund to ensure that USAID can quickly and effectively respond to emerging infectious disease outbreaks posing severe threats to human health.”
x — The FY23 Omnibus states that “up to $90,000,000 of the funds made available under the heading ‘Global Health Programs’ may be made available for the Emergency Reserve Fund.”
xi — The FY23 Request states that the Health Resilience Fund (HRF) “will support cross-cutting health systems strengthening in challenging environments or countries emerging from crisis.”
xii — The explanatory statement accompanying the FY23 Omnibus states that these funds are “to support cross-cutting health activities, including health service delivery, the health workforce, health information systems, access to essential medicines, health systems financing, and governance, in challenging environments and countries in crisis.”
xiii — The FY22 Final bill “includes $100,000,000 for a U.S. contribution to support a multilateral vaccine development partnership for epidemic preparedness innovations.”

Resources:

“Consolidated Appropriations Act, 2023” – Bill Text
FY2023 Department of State, Foreign Operations, and Related Programs (SFOPs) Appropriations – Explanatory Statement
FY2023 Department of Labor, Health and Human Services, and Education, and Related Agencies (Labor HHS) Appropriations – Explanatory Statement

[i] Total funding for global health is not currently available as some funding provided through USAID, NIH, and DoD is not yet available.

Poll Finding

KFF Health Tracking Poll December 2022: The Public’s Health Care Priorities For The New Congress

Authors: Shannon Schumacher, Lunna Lopes, Grace Sparks, Marley Presiado, Liz Hamel, and Mollyann Brodie

Published: Dec 20, 2022

Section:

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Findings

Key Findings:

With the rising cost of living at the top of the public’s mind, the latest KFF Health Tracking poll finds that the public wants lawmakers to prioritize the economy and combatting inflation in the upcoming Congressional term. When asked specifically about health care priorities for Congress, passing a law to make health care costs more transparent to patients tops the list, with 60% calling this a top priority. And nearly three years into the pandemic and at a time when government COVID-19 funding may come to an end, three in ten (31%) say Congress should prioritize continuing funding for COVID-19 vaccines and treatment.
In the wake of the Dobbs decision overturning Roe v. Wade, President Biden pledged that the first bill he would send to the new Congress would be one to protect abortion rights. And though such a bill has little chance of passing in a divided Congress, this month’s KFF Health Tracking poll finds that two in three adults (65%) say passing a law to make abortion legal in all states is important, including four in ten (42%) who say it should be a top priority for Congress. Majorities across key groups say legalizing abortion nationwide should be a top priority for Congress, including Democrats and those who lean toward the party (66%), adults under 30 (58%), women under 50 (58%), and Black adults (55%). However, about one in four (26%) of the public overall and about half (49%) of Republicans and Republican-leaning independents say codifying the right to abortion nationwide is something Congress should not
Worries about rising prices are widespread among the public and health care costs are no exception. Nine in ten (91%) say they are concerned about increases in health care costs for individuals, including six in ten who say they are very concerned, nearly double the share who say they are very concerned about increases in government insurance programs like Medicare and Medicaid (34%) or about increases in health care costs paid by employers (31%). About half (48%) of the public say they are very worried about increases in health care costs for the nation as a whole.
Although there is great concern among the public about increases in health care costs, many have false impressions about where most U.S. health care money is spent. When asked where they think most health care spending goes, the most frequent answer given by the public is prescription drugs (36%), followed by hospitals (30%), long-term care (19%), and physician services (11%). Analyses of overall national health spending in 2020 found that the largest share of the U.S. health care dollar is spent on hospitals, while physicians/clinics and prescription drugs account for a smaller share of national health expenditures.
The costs associated with mental health care are another area where the public wants Congress to take action. Majorities say it should be a top priority for Congress to strengthen mental health parity laws (54%) and to increase funding for access to mental health services (51%). And, nearly eight in ten (79%) adults say that health insurance companies not covering mental health services like they do physical health is a big problem for mental health in the U.S., while a similar share (77%) say the same about the cost of mental health care.
Four months after the signing of the Inflation Reduction Act (IRA), at least seven in ten say they support each of the health care provisions polled, all of which aim to reduce patient costs. Support is highest for the provisions that aim to reduce costs for people on Medicare, such as capping monthly costs for prescription drugs, insulin, and allowing the government to negotiate for the price of prescription drugs. This includes majorities across partisans, though the majority that supports extending Affordable Care Act subsidies under the ACA is notably smaller among Republicans than among Democrats (54% vs. 90%).

The Public’s Top Priorities For The New Congress: Focusing On The Economy And Reducing Health Care Costs

Just as KFF analysis of APVotecast data found that inflation was the top factor motivating voters in midterm elections, the December KFF Health Tracking Poll finds that the economy and inflation is the public’s top issue for Congress in its upcoming term. More than one in three (37%) adults cite economic concerns when asked in their own words what should be the top priority for Congress in its new session next year, including 28% who mention inflation specifically.

Health care (including health care costs) is the second-most frequently mentioned priority by the public (9%), followed by immigration (8%). Other priorities were mentioned by smaller shares of adults, such as abortion and reproductive (5%), guns, crime and safety (4%), climate change, the environment, and global warming (3%), and democracy and election and voting reform (3%).

Economic Concerns Top The Public’s List Of Priorities For The New Congress

While the economy is the most frequently mentioned topic regardless of partisanship, Republicans and those who lean toward the party are twice as likely to name economic concerns as a top Congressional priority than are Democrats and Democratic leaners (50% vs. 26%). Beyond the economy and inflation, partisans differ somewhat in what they think Congress should prioritize in its new term. Among Democrats and those who lean toward the party, health care and health care affordability is the second most frequently mentioned topic (13%), while immigration is the second most frequently raised issue among Republicans and those who lean Republican (12%). A number of other priorities are named by at least 5% of Democrats, including abortion and reproductive rights; guns, crime and safety; democracy and election and voting reform; and climate change. Much smaller shares of Republicans mention each of these priorities.

Partisans Prioritize Economic Concerns Most, But Differ Across Other Top Concerns For New Congress

HEALTH CARE PRIORITIES FOR THE NEW CONGRESS

When asked specifically about health care priorities that Congress could take on next term, the public sees many as important for Congress to tackle. While recent regulations have sought to improve both price transparency and mental health care access, both of these issues are at the top of the public’s priority list for Congress. A large majority (95%) of the public say it is important for Congress to pass a law to make health care costs more transparent to patients, including 60% who call this a top priority.

On mental health, large shares say Congress should prioritize strengthening requirements to make health insurance plans cover mental health as they do physical health (91% important, including 54% top priority), as well as increasing funding for access to mental health services (92% important, 51% top priority). Another mental health priority, increasing funding to expand treatment programs for opioid addiction, is seen as important by about eight in ten adults (79%), but fewer (30%) say it should be a top priority for Congress.

Two policies related to women’s health are also seen as important areas for Congressional action by majorities of the public. About two-thirds (65%) say it is important for Congress to pass a law to make abortion legal in all states, including 42% who call this a top priority. Three-quarters (75%) also say it’s important for Congress to pass a law that requires states to continue coverage for 12 months after childbirth for pregnant people on Medicaid, including 35% who say this should be a top priority.

The Biden Administration recently announced that barring further Congressional action, the government will no longer fund the purchase of COVID-19 vaccines, which would likely increase spending on vaccines by billions of dollars a year according to an analysis by KFF. While seven in ten say continuing funding for COVID-19 vaccines is important for Congress to do, it ranks lower on the public’s priority list, with three in ten (31%) saying it should be a top priority.

Rounding out the list of health care priorities for the new Congress, seven in ten adults say it’s important for Congress to pass a law providing expanded access to telehealth services, though just two in ten call this a top priority. The relatively lower ranking of this issue may reflect the decline in the use of telehealth for outpatient visits, which peaked at 13% between March and August of 2020 according to KFF analysis.

Large Majorities Support Health Care Price Transparency And Mental Health Initiatives

On nearly all of these issues, women, Democrats, and those with lower incomes are more likely to see each of these as priorities for Congress.

Price Transparency And Mental Health Care Expenses Top Health Care Priorities For Congress

Majorities across key demographics say PROTECTING ABORTION ACCESS is IMPORTANT for new congress

As KFF analysis of AP VoteCast data has shown, the overturn of Roe v. Wade this summer played an outsize role in shaping the minds of many voters in the recent midterm election. Now, looking ahead to the new Congressional term, about two-thirds (65%) of the public say passing a law to make abortion legal in all states is an important thing for Congress to do in its new term, including 42% who say it should be a top priority.

On this topic, 50% of women say it should be a top priority compared to one third (33%) of men. And Democrats and those who lean toward the party are about four times more likely than Republicans and those who lean Republican (66% vs. 17%) to say Congress should prioritize legalizing abortion nationwide. Notably, 26% of the public overall, including about half (49%) of Republicans and Republican leaners say that legalizing abortion is something Congress should not do.

About half of voters age 18-29 and women voters ages 18-49 said in November’s KFF/AP VoteCast poll that the Supreme Court overturning Roe v. Wade had a major impact on their decision about whether to vote in the midterm election, and a similar share said it also had a major impact on which candidates they supported in the election. This month’s KFF Health Tracking Poll finds majorities among these groups say legalizing abortion nationwide should be a top for the new Congress. Nearly six in ten adults under 30 (58%) and women under 50 (58%) say passing a law to legalize abortion in all states is a top priority, while similar shares of Black adults (55%) say the same.

Two In Three Favor Nationwide Abortion Protections, With Support Higher Among Key Groups

Another policy affecting women’s access to health care, passing a law that requires states to continue coverage for 12 months after childbirth for pregnant people on Medicaid, is seen as important by three-quarters of the public (75%). Fewer (35%) see this as a top priority for Congress, though the share who say it is a top priority rises to 50% for Democrats and those who lean Democratic and 41% for women. About one in two (51%) adults under 30 say passing a law to continue Medicaid coverage for 12 months postpartum is a top Congressional priority, while only about one in four (23%) adults 50 and older say the same. Majorities of women 18-49 (54%), Black adults (54%), and about half (49%) of Hispanic adults also say expanding postpartum Medicaid coverage should be a top priority for the new Congress. Currently, expansion of Medicaid coverage for 12 months after childbirth is optional for states, and about two thirds of states have implemented or plan to implement such coverage.¹

Three In Four Adults Favor Extending Medicaid Coverage For 12 Months After Childbirth

Concerns About Health Care Costs And National Health Care Expenditures

Just as the economy, inflation, and health care are at the top of the public’s priority list for the new Congress, when asked directly about increases in health care costs the public is concerned. About nine in ten (91%) say they are concerned about increases in the amount individuals pay for health care, including six in ten (60%) who say they are “very” concerned. About eight in ten (83%) say they are concerned about increases in what the nation as a whole spends on health care, including nearly half (48%) who say they are “very” concerned. The public is somewhat less concerned about increases in spending when it comes to increases in costs borne by the government and employers. Around three in ten say they are “very” concerned about increases in spending on government health insurance programs like Medicare and Medicaid (34%), or the amount employers pay for their employees’ health care (31%).

Majorities Express Concern Over Health Care Spending In The U.S., With Particular Concern About Individuals' Spending

MANY SAY most health care spending is on prescription drugs, followed by hospitals

While the public is greatly concerned about increases in health care costs, many harbor misconceptions about where most of the U.S. health care dollar is spent. When asked about where they think most of health care spending by government and individuals goes, the most frequent answer given by the public is prescription drugs (36%), followed by hospitals (30%). About one in five adults say long-term care (19%) is where most money is spent, and about one in ten (11%) say physician services.

While it is true that the U.S. spends significantly more on prescription drugs than other comparatively wealthy nations on average according to the Peterson-KFF Health System Tracker, analyses of overall national health spending found that hospitals represented nearly a third (31%) of spending, while physicians/clinics accounted for one fifth (20%) and prescription drugs a further 8%.

Prescription Drugs Thought To Be The Highest Spend Category In U.S. Health Care, With Hospitals A Close Second

Majorities Cite Lack Of Health Insurance Coverage And Costs As Key Concerns For Mental Health Care In The U.S.

Expense and overall costs also emerge as key issues when it comes to the public’s concerns about mental health in the United States. Similar to the shares found in an in-depth survey of mental health KFF conducted with CNN in July-August of this year, the latest KFF Health Tracking Poll finds that majorities say each of the items polled are big problems when thinking about mental health in the U.S. About eight in ten (79%) adults say that health insurance companies not covering mental health services like they do physical health is a big problem, while a similar share (77%) say the same about the cost of mental health care.

Beyond these expense-related problems, about two in three adults say stigma or shame associated with mental health is a big problem (66%), and a similar share (68%) say it is a big problem that there are not enough health care providers, such as therapists or counselors.

Women and those who report having a mental health condition are more likely to say each of these issues polled are a big problem when it comes to mental health in the U.S. than were men and those who do not report having a mental health condition.

Expense And Access Identified As Top Problems For Mental Health In The U.S.

Majorities Support Key Health Care Provisions Of The Inflation Reduction Act

Four months after President Joe Biden signed the Inflation Reduction Act (IRA) into law, most adults (71%) say they have read or heard at least a little about the law, though relatively few (13%) say they have heard “a lot.”

When asked about some specific health care components of the IRA, majorities of the public are in support. More than eight in ten adults support capping monthly-out-of-pocket costs for insulin for people with Medicare (84%) as well as placing a limit on out-of-pocket prescription drug costs for people with Medicare (82%). A similar share (81%) supports authorizing the federal government to negotiate the price of some prescription drugs for people with Medicare. And although the law was passed along party lines with all Democratic representatives in favor and no supporting Republican votes, large majorities across partisans in the public say they are in support of each of these provisions.

In addition to the Medicare provisions of the IRA, there is also strong support for the provision that extends financial subsidies for people who purchase health coverage through the Affordable Care Act marketplace. About seven in ten (72%) adults support this component of the law, though there is a strong partisan divide. The vast majority of Democrats and those who lean toward the party support this measure compared to a smaller majority of their Republican (90% v. 54%).

Strong Support For IRA Health Care Provisions, Especially Those That Reduce Costs For People With Medicare

Methodology

This KFF Health Tracking Poll/COVID-19 Vaccine Monitor Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted November 29 – December 8, 2022, online and by telephone among a nationally representative sample of 1,259 U.S. adults in English (1,203) and in Spanish (56). The sample includes 1,029 adults reached through the SSRS Opinion Panel^[1] either online or over the phone (n=32 in Spanish). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails. 1,004 panel members completed the survey online and panel members who do not use the internet were reached by phone (n=25).

Another 230 (n=24 in Spanish) interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Respondents in the phone samples received a $15 incentive via a check received by mail, and web respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card).

The online questionnaire included two questions designed to establish that respondents were paying attention. Cases that failed both attention check questions, those with over 30% item non-response, and cases with a length less than one quarter of the mean length by mode were flagged and reviewed. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, one case was removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). Weighting parameters included sex, age, education, race/ethnicity, region, and education. The sample was weighted to match patterns of civic engagement from the September 2017 Volunteering and Civic Life Supplement data from the CPS and to match frequency of internet use from the National Public Opinion Reference Survey (NPORS) for Pew Research Center. Finally, the sample was weighted to match patterns of political party identification based on a parameter derived from recent ABS polls conducted by SSRS polls. The weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 4 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

Group	N (unweighted)	M.O.S.E.
Total	1,259	± 4 percentage points

Race/Ethnicity
White, non-Hispanic	771	± 5 percentage points
Black, non-Hispanic	190	± 10 percentage points
Hispanic	226	± 9 percentage points

Party identification
Democrat	463	± 6 percentage points
Republican	327	± 7 percentage points
Independent	297	± 8 percentage points
Democrats/Democratic-leaning independents	620	± 5 percentage points
Republicans/Republican-leaning independents	454	± 6 percentage points

Parents
Total parents	377	± 7 percentage points
Parent with a child ages 6 months through 4 years old	133	± 11 percentage points
Parent with a child ages 5-11	201	± 9 percentage points
Parent with a child ages 12-17	193	± 10 percentage points

[1] https://ssrs.com/opinion-panel/

Endnotes

Data as of December 8, 2022. ↩︎

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News Release

Large Shares of Women Report Needing Mental Health Services but Many Don’t Get Them

Published: Dec 20, 2022

An analysis of 2022 KFF Women’s Health Survey (WHS) data finds that although large shares of women report needing mental health services over the past two years, a significant percentage did not access services they felt they needed. Fifty percent of women ages 18-64 say they needed mental health services in the past two years (including 64% of women ages 18-25), but only half of these women obtained an appointment, which may suggest unmet mental health care needs.

Among those who felt they needed care, one in ten (10%) tried to get care but were unable to make an appointment for mental health services. Another 40% did not try to get mental health services even though they say they needed them.

Research has documented the challenges some consumers with health insurance face when finding in-network care. In fact, two in ten privately insured women with a mental health appointment in the past two years say their provider did not accept their insurance.

The country also faces a workforce shortage of behavioral health professionals in addition to other affordability challenges with health care infrastructure that impede accessibility. Among the one in six women who say they needed and sought mental health care services but were unable to get an appointment (16%), one-third say the main reasons they were unable to get an appointment were that they could not find a provider that was accepting new patients (33%) or that they could not afford the cost of mental health services (33%).

Conducted periodically since 2001, the 2022 KFF Women’s Health Survey (WHS) includes a nationally representative sample of 5,145 women and 1,225 men ages 18-64 conducted primarily online from May 10, 2022, to June 7, 2022. Our analyses present the state of health services access and utilization among women and men by income, race and ethnicity, insurance status, and other demographic characteristics.

Review “Access and Coverage for Mental Health Care” and explore “Experiences with Health Care Access, Cost, and Coverage,” which presents findings from the 2022 KFF WHS on women’s health status, use of health care services including telehealth, and costs.

Contact

Rakesh Singh

KFF

rsingh@kff.org

Access and Coverage for Mental Health Care: Findings from the 2022 KFF Women’s Health Survey

Authors: Karen Diep, Brittni Frederiksen, Michelle Long, Usha Ranji, and Alina Salganicoff

Published: Dec 20, 2022

Section:

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Issue Brief

Key Takeaways

A significantly higher share of women (50%) than men (35%) thought they needed mental health services in the past two years. Among those who thought they needed mental health care, about six in ten women and men sought care in the past two years.
Nearly two-thirds of young women ages 18-25 report needing mental health care in the past two years compared to one-third of women ages 50-64.
Among all women ages 18-64 who thought they needed mental health services in the past two years, just half tried and were able to get an appointment for mental health care, 10% tried but were unable to get an appointment, and 40% did not seek care.
Almost half of women who needed mental health services and tried to get care were able to get an appointment within a month, but more than one-third of women had to wait more than a month. Among those who could not get an appointment, women cite limited provider availability and cost as the main reasons they were unable to access mental health care.
Two in ten privately insured women with a mental health appointment in the past two years say their provider did not accept their insurance.
Sixty percent of women had a telemedicine/telehealth visit in the past two years. Mental health care was the third most common reason women cited for accessing telehealth/telemedicine services, with 17% saying it was the primary purpose of their most recent telemedicine visit. The majority report that the quality of their telehealth visit was the same as an in-person visit.

Introduction

Mental health has emerged as a rapidly growing concern in recent years, with 90% of Americans saying there is a mental health crisis in a recent KFF-CNN poll. Women experience several mental health conditions more commonly than men, and some also experience mental health disorders that are unique to women, such as perinatal depression and premenstrual dysphoric disorders that may occur when hormone levels change. Data from the National Center for Health Statistics show that across all age groups, women were almost twice as likely to have depression and anxiety than men. The COVID-19 pandemic, the opioid epidemic, and racism are among commonly cited stressors that have exacerbated long-standing mental health issues and prompted growing demand for mental health services in the past two years, particularly among women.

This brief provides new data from the 2022 KFF Women’s Health Survey (WHS), a nationally representative survey of 5,145 women and 1,225 men ages 18-64 conducted primarily online from May 10, 2022, to June 7, 2022. In addition to several topics related to reproductive health and well-being, the survey asked respondents about their experiences accessing mental health services in the past two years. This issue brief presents KFF WHS data on mental health services access among self-identified women and men ages 18-64, and it also takes a closer look at mental health coverage among women. People of all genders, including non-binary people, were asked these questions; however, there are insufficient data to report on non-cisgendered people. See the Methodology section for details.

Utilization of Mental Health Services

Gender Differences

Half of women ages 18-64 (50%) thought they needed mental health services in the past two years (Figure 1) and a significantly smaller share of men report they needed mental health care (35%). Studies have long documented gender disparities in the rates and types of mental health conditions. Among those who thought they needed care, however, similar rates of women and men report seeking care. Sixty percent of women tried to make an appointment for mental health compared to 56% of men.

A Higher Share of Women Than Men Report Needing Mental Health Services0

Need and Care Seeking

Nearly two thirds (64%) of women ages 18-25 thought they needed mental health services at some point in the past two years compared to just 35% of women ages 50-64 (Figure 2). Previous findings from the 2020 KFF WHS revealed that more than half of women (51%) said that worry or stress related to the coronavirus had affected their mental health. Other studies show that young adults, particularly women, experienced high incidence of depression and loneliness during the early stages of the pandemic.

More than half of women with low incomes (< 200% of the federal poverty level (FPL)) (55%) and women with Medicaid coverage (58%) thought they needed mental health care in the past two years compared to less than half (47%) of women with higher incomes (≥ 200% FPL) and those with private insurance (includes employer-sponsored insurance and individually purchased insurance) (47%). The FPL in 2022 for an individual is $13,590 (Figure 2).

Over Half of Young Women and Women with Low Incomes Report the Need for Mental Health Care

Among those who thought they needed mental health care, larger shares of women ages 26-35 (63%) and women ages 36-49 (64%) sought care compared to 55% of women ages 50-64. Larger shares of women enrolled in Medicaid (67%) sought mental health services compared to women who have private insurance (58%) and women who are uninsured (50%) (Figure 3).

A significantly lower share of Asian/Pacific Islander women (40%) say they needed mental health services at some point in the past two years than their White counterparts (50%). Although not statistically significant, smaller shares of Asian/Pacific Islander women report seeking care compared to White women (50% vs. 62%). While the pandemic fueled violence against Asians and subsequently worsened anxiety and mental health for many, studies have shown that Asians reported greater cultural barriers to help-seeking such as family stigma and concerns about “losing face.” Cultural barriers may influence perceived need of care in addition to help-seeking behaviors.

Although the self-reported need for mental health care did not differ between Hispanic and White women (both 50%), smaller shares of Hispanic women (56%) sought care compared to White women (62%). Despite high rates of depression among Hispanic women, studies have shown that stigma and perceived discrimination in health care settings can contribute to underutilization of mental health services within Hispanic communities. Hispanic women also have the highest uninsured rate, which may limit their access to care.

Among Those Who Needed Care, Larger Shares of Women Who Were Younger and Covered by Medicaid Sought Mental Health Care

Among the 50% of women who thought they needed mental health services, half (50%) were able to get an appointment, while another 40% did not try to get mental health services (Figure 4). One in ten (10%) who tried to get care were unable to make an appointment for mental health services. This suggests that the other half of women who report needing care may have unmet mental health needs.

Among Women Who Thought They Needed Mental Health Care in the Past Two Years, Half Were Able to Get an Appointment for Care

Among all women who thought they needed mental health care and tried to get it in the past two years, nearly half (47%) had to wait less than a month for an appointment (Figure 5). One-quarter (24%) had to wait one to two months, and 13% had to wait more than two months to get care. The remaining 16% of those who sought mental health care could not get an appointment.

Among the 16% of women who needed care, sought care, and were unable to get an appointment for mental health services, the main reasons were limited provider availability and cost barriers. One-third of women who could not get an appointment say the main reasons were that they could not find a provider that was accepting new patients (33%) or that they could not afford the cost of mental health services (33%). Eight percent could not get an appointment in a reasonable amount of time and six percent say they could not find a provider nearby. Another 6% say they could not get an appointment for another reason, such as not wanting to go in-person due to COVID-19.

Our findings on provider availability are consistent with other studies on mental health access. A report from the U.S. Government Accountability Office found that many consumers with health insurance faced challenges finding in-network care. The country also faces a workforce shortage of behavioral health professionals in addition to other challenges with health care infrastructure that exacerbates issues with accessibility.

Figure 5: Women Were Unable to Access Mental Health Care Largely Due to Cost Barriers and Limited Provider Availability

Cost and Coverage for Mental Health Services

Among those who sought care but could not get an appointment, one-third (33%) say the main reason was that they could not afford it (Figure 5). Cost remains a barrier to mental health care access for some people with insurance and especially for those who lack coverage. Significantly larger shares of women who are uninsured (60%) say they could not get an appointment due to affordability reasons, compared to those who have health insurance either through private plans (33%) or Medicaid (30%) (Figure 6). There were no significant differences between women who have private insurance and women covered by Medicaid.

These findings on cost barriers are consistent with current literature, which has found that along with provider availability, affordability is one of the most prevalent barriers to mental health care.

Among Women Who Could Not Get an Appointment for Mental Health Services, One-Third Cite Cost as the Barrier

While federal laws require special insurance protections such as parity for mental health care, gaps in coverage remain. All state Medicaid programs provide coverage for mental health services, and the Affordable Care Act (ACA) requires most private insurers to cover mental health care. However, the scope of coverage varies, provider networks are limited in many plans, and mental health providers may not accept all insurance plans. Some mental health practitioners do not accept insurance of any kind.

While most privately insured women who received mental health services in the past two years say their provider accepted their insurance for their most recent mental health visit (81%), two in ten (19%) say their provider did not. Among privately insured women who said their provider accepted their insurance, more than half report having out-of-pocket expenses for their most recent mental health visit. More than one-third (36%) say their insurance covered the full cost and 52% say their insurance covered some of the cost. Three percent say their insurance did not cover any of the cost. (Figure 7).

Figure 7: Two in Ten Privately Insured Women Who Got Mental Health Care Say Their Provider Did Not Accept Their Insurance

The Affordable Care Act requires that enrollees in most private health insurance plans have the right to appeal denied claims, though some evidence suggests that many are unfamiliar with appeals processes or are unaware of this protection. Among privately insured women whose insurance was not accepted by their mental health provider, 27% filed a claim with the health insurance plan to try to get reimbursed for some or all the cost (data not shown).

Telehealth

Social distancing during the pandemic contributed to a sharp increase in the provision of telehealth services, widening the access of counseling, therapy, prescribing, and other services via remote methods such as video and telephone. The rapid expansion of telemedicine/telehealth over the course of the COVID-19 pandemic has broadened access to health care for many, including access to mental health services. Mental health services provided via telehealth include speaking to a mental health provider over telephone or video, or through online apps such as Talkspace.

Sixty percent of women ages 18-64 had a telemedicine/telehealth visit in the past two years. Among these women, 17% say the primary purpose of their most recent visit was for mental health services (Figure 8). Accessing mental health care services was the third most common reason for telehealth visits, following annual check-ups (18%) and visits for minor illness or injury (18%). Three in ten women ages 18-25 (29%) say their most recent telehealth visit was for mental health services compared to 20% of women ages 26 to 35, 18% of women ages 36 to 49, and 10% of women ages 50 to 64 and older. A larger share of White women (21%) obtained mental health services at their most recent telehealth visit than Black women (13%), Hispanic women (14%), and Asian/Pacific Islander women (7%).

A larger share of women with Medicaid coverage (22%) report that their most recent telemedicine or telehealth visit was for mental health services than women who are privately insured (15%).

A similar share of women living in rural (23%) and urban/suburban (17%) areas report that the primary purpose of their most recent telehealth or telemedicine visit was for mental health services.

Nearly One-in-five Telehealth Users Accessed Mental Health Services at Their Most Recent Visit

The majority (69%) of women who had a telehealth or telemedicine visit in the past two years for mental health care say the quality of care they received at their most recent visit was the same as an in-person visit for this type of care (Figure 9). One-in-five (19%) report receiving better quality of care during their telehealth visit, while 12% report experiencing worse quality than an in-person visit. These findings suggest the quality of mental health care is typically not diminished when accessing care via telehealth.

Most Women Rate the Quality of Their Telehealth Visit as Comparable to Their In-Person Mental Health Visit

Conclusion

The demand for mental health care continues to surge as wait lists for professional help grow. Recent reports reveal that mental health providers across the nation are facing an overwhelming demand for services, leaving many individuals without care. Our survey finds that among the half of women who report that they thought they needed mental health services in the past two years, only half got an appointment for care. Unmet mental health needs are known to affect the overall well-being and productivity of individuals, families, and society, and studies have consistently shown that women are disproportionately affected by these unmet needs. Data from the 2022 KFF WHS underscore that addressing issues with provider availability and cost could improve access to mental health care for some. Our findings suggest that affordability barriers are a substantial obstacle for uninsured women.

In response to the COVID-19 pandemic and other changes in the health policy environment, larger shares of employers began expanding coverage of mental health services by including more providers for in-person and telehealth care. Telehealth and telemedicine services have been recognized as an evolving strategy to increase access to care and address health needs, including care for mental health. We found that most women who received mental health services via telehealth say the quality of care they received was the same as in-person care. Telehealth has and likely will continue to play a role in addressing mental health access concerns for women.

Despite federal and state laws intended to expand and strengthen coverage for mental health care, gaps in coverage and problems with affordability continue to hinder access to mental health services even for those with private insurance and Medicaid. Our survey finds that in addition to challenges obtaining services, many women who have insurance faced at least some out-of-pocket costs for their visit. The findings from the 2022 KFF WHS suggest that future policies affecting telehealth, provider availability, health insurance coverage, and affordability will play a significant role in addressing the demand for mental health care.

Methodology

Overview

The 2022 KFF Women’s Health Survey is a nationally representative survey of 6,442 people ages 18 to 64, including 5,201 females (self-reported sex at birth) and 1,241 males, conducted from May 10, 2022, to June 7, 2022. The objective of the survey is to help better understand respondents’ experiences with contraception, potential barriers to health care access, and other issues related to reproductive health. The survey was designed and analyzed by researchers at KFF (Kaiser Family Foundation) and fielded online and by telephone by SSRS using its Opinion Panel, supplemented with sample from IPSOS’s KnowledgePanel.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Questionnaire design

KFF developed the survey instrument with SSRS feedback regarding question wording, order, clarity, and other issues pertaining to questionnaire quality. The survey was conducted in English and Spanish. The survey instrument is available upon request.

Sample design

The majority of respondents completed the survey using the SSRS Opinion Panel (n=5,202), a nationally representative probability-based panel where panel members are recruited in one of two ways: (1) through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Group through the U.S. Postal Service’s Computerized Delivery Sequence. (2) from a dual-framed random digit dial (RDD) sample provided by Marketing Systems Group.

In order to have large enough sample sizes for certain subgroups (females ages 18 to 35, particularly females in the following subgroups: lesbian/gay/bisexual; Asian; Black; Hispanic; Medicaid enrollees; low-income; and rural), an additional 1,240 surveys were conducted using the IPSOS KnowledgePanel, a nationally representative probability-based panel recruited using a stratified ABS design.

Data collection

Web Administration Procedures

The majority of surveys completed using the SSRS Opinion Panel (n=5,056) and all of the surveys completed using the KnowledgePanel (n=1,240) were self-administered web surveys. Panelists were emailed an invitation, which included a unique passcode-embedded link, to complete the survey online. In appreciation for their participation, panelists received a modest incentive in the form of a $5 or $10 electronic gift card. All respondents who did not respond to their first invitation received up to five reminder emails and panelists who had opted into receiving text messages from the SSRS Opinion Panel received text message reminders.

Overall, the median length of the web surveys was 13 minutes.

Phone Administration Procedures

In addition to the self-administered web survey, n=146 surveys were completed by telephone with SSRS Opinion Panelists who are web reluctant. Overall, the median length of the phone surveys was 28 minutes.

Data processing and integration

SSRS implemented several quality assurance procedures in data file preparation and processing. Prior to launching data collection, extensive testing of the survey was completed to ensure it was working as anticipated. After the soft launch, survey data were carefully checked for accuracy, completeness, and non-response to specific questions so that any issues could be identified and resolved prior to the full launch.

The data file programmer implemented a “data cleaning” procedure in which web survey skip patterns were created in order to ensure that all questions had the appropriate numbers of cases. This procedure involved a check of raw data by a program that consisted of instructions derived from the skip patterns designated on the questionnaire. The program confirmed that data were consistent with the definitions of codes and ranges and matched the appropriate bases of all questions. The SSRS team also reviewed preliminary SPSS files and conducted an independent check of all created variables to ensure that all variables were accurately constructed.

As a standard practice, quality checks were incorporated into the survey. Quality control checks for this study included a review of “speeders,” reviewing the internal response rate (number of questions answered divided by the number of questions asked) and open-ended questions. Among all respondents, the vast majority (97%) answered 96% or more of the survey questions they received, with no one completing less than 91% of the administered survey (respondents were informed at the start of the survey that they could skip any question).

Weighting

The data were weighted to represent U.S. adults ages 18 to 64. The data include oversamples of females ages 18 to 35 and females ages 36 to 64. Due to this oversampling, the data were classified into three subgroups: females 18 to 35, females 36 to 64, and males 18 to 64. The weighting consisted of two stages: 1) application of base weights and 2) calibration to population parameters. Each subgroup was calibrated separately, then the groups were put into their proper proportions relative to their size in the population.

Calibration to Population Benchmarks

The sample was balanced to match estimates of each of the three subgroups (females ages 18 to 35, females ages 36 to 64, and males ages 18 to 64) along the following dimensions: age; education (less than a high school graduate, high school graduate, some college, four-year college or more); region (Northeast, Midwest, South, West); and race/ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic-born in U.S., Hispanic-born Outside the U.S., Asian non-Hispanic, Other non-Hispanic). The sample was weighted within race (White, non-Hispanic; Black, non-Hispanic; Hispanic; and Asian) to match population estimates. Benchmark distributions were derived from 2021 Current Population Survey (CPS) data.

Weighting summaries for females ages 18 to 35, females ages 36 to 64, and males ages 18 to 64 are available upon request.

Finally, the three weights were combined, and a final adjustment was made to match the groups to their proper proportions relative to their size in the population (Table 1).

Margin of Sampling Error

The margin of sampling error, including the design effect for subgroups, is presented in Table 2 below. It is important to remember that the sampling fluctuations captured in the margin of error are only one possible source of error in a survey estimate and there may be other unmeasured error in this or any other survey.

Design Effects and Margins of Error by Demographic Group

KFF Analysis

Researchers at KFF conducted further data analysis using the R survey package, including creating constructed variables, running additional testing for statistical significance, and coding responses to open-ended questions. The survey instrument is available upon request.

Rounding

Some figures in the report do not sum to totals due to rounding. Although overall totals are statistically valid, some breakdowns may not be available due to limited sample sizes or cell sizes. Where the unweighted sample size is less than 100 or where observations are less than 10, figures include the notation “NSD” (Not Sufficient Data).

Statistical significance

All statistical tests are performed at the .05 confidence level. Statistical tests for a given subgroup are tested against the reference group (Ref.) unless otherwise indicated. For example, White is the standard reference for race/ethnicity comparisons and private insurance is the standard reference for types of insurance coverage. Some breakouts by subsets have a large standard error, meaning that sometimes even large differences between estimates are not statistically different.

A note about sex and gender language

Our survey asked respondents which sex they were assigned at birth, on their original birth certificate (male or female). They were then asked what their current gender is (man, woman, transgender, non-binary, or other). Those who identified as transgender men are coded as men and transgender women are coded as women. While we attempted to be as inclusive as possible and recognize the importance of better understanding the health of non-cisgendered people, as is common in many nationally representative surveys, we did not have a sufficient sample size (n >= 100) to report gender breakouts other than men and women with confidence that they reflect the larger non-cisgender population as a whole. The data in our reproductive health reports use the respondent’s sex assigned at birth (inclusive of all genders) to account for reproductive health needs/capacity (e.g., ever been pregnant) while the data in our other survey reports use the respondent’s gender.

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Experiences with Health Care Access, Cost, and Coverage: Findings from the 2022 KFF Women’s Health Survey

Authors: Michelle Long, Brittni Frederiksen, Usha Ranji, Alina Salganicoff, and Karen Diep

Published: Dec 20, 2022

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