The high cost of emergency care may impact patients’ ability to afford treatment, with almost half of US adults reporting they have delayed care due to costs. This analysis uses 2019 insurance claims data from the Merative MarketScan Commercial Database, which captures privately insured individuals with large employer health plans, to assess the total and out-of-pocket costs of emergency department visits for this group, overall and by diagnosis and severity level. It also looks at which services contribute most to the costs of emergency department visits and examine regional variation in emergency department costs and provides a demographic profile of consumers who visited the emergency department.

It find that enrollees spend $646 out-of-pocket, on average, for an emergency department visit. The most expensive components of most emergency department visits include evaluation and management charges, imaging, and laboratory studies. Cost varies by disease, visit complexity, and geographic region.

The full analysis is available through the Peterson-Kaiser Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Amid controversies around the COVID-19 vaccine and growing distrust of public health authorities, more than four in ten Republicans and Republican-leaning independents, and a third of parents, now say they oppose requiring children in public schools to receive some childhood vaccines, up since 2019, a new KFF COVID-19 Vaccine Monitor survey finds.

Overall, nearly three in ten adults (28%) nationally now say that parents should be able to decide not to vaccinate their children for measles, mumps, and rubella rather than those vaccinations being required to attend public schools, up from 16% in a 2019 Pew Research Center poll conducted before the COVID-19 pandemic. Among parents, opposition to requiring those childhood vaccines now stands at 35%, up from 23% in 2019.

While most of the public still say that healthy children should be required to get those vaccines to attend public schools (71%), that share is down from 82% in 2019.

The growing opposition stems largely from shifts among people who identify as Republican or lean Republican, with 44% now saying parents should be able to opt out of those childhood vaccines, up from 20% in 2019.  In contrast, the vast majority of Democrats and those who lean Democratic support requiring the vaccines for public school students (88%), little changed from 2019 (86%).

Currently, all states and the District of Columbia require children to be vaccinated against certain diseases, including measles and rubella, in order to attend public schools, though exemptions are allowed in certain circumstances.

Despite growing opposition to requiring childhood vaccines, the new survey captures only modest shifts in the public’s view of their value. Today 85% of the public and 80% of parents say the benefits of the measles, mumps and rubella vaccines outweigh their risks, little changed from 2019, when 88% of the public and 83% of parents felt that way.

Even among people who have not gotten a COVID-19 vaccine, a large majority (70%) say the benefits of these childhood vaccines outweigh the risks, though one in four (26%) say the risks outweigh the benefits.

The new survey also finds that about four in ten adults report that they either have already gotten the recommended bivalent booster shot (22%) or say they will get it as soon as they can (16%). The bivalent booster targets both the original and omicron COVID-19 strains and has been available since September.

Among adults ages 65 and older, who face higher risks from COVID-19, about four in ten (39%) say they have already gotten the bivalent booster, and another 16% say they intend to do so as soon as possible. Still, this currently leaves more than half of older adults without the protection of the bivalent booster.

Democrats (38%) are much more likely than independents (18%) or Republicans (12%) to say that they’ve gotten the new booster.

Vaccinated adults who have not gotten a bivalent booster are largely skeptical about its value. Among this group, more than four in ten (44%) say they don’t think they need the new booster, and more than a third (37%) say that they don’t think its benefits are worth it. A similar share (36%) say they are too busy and haven’t had time to get it.

Fewer cite other reasons such as bad side effects from earlier COVID-19 vaccines (23%), waiting to see if cases increase in their area (17%), or waiting until they travel or see vulnerable family and friends (12%).

Among those ages 65 and older who are vaccinated but have not gotten the updated booster, about a third say that they don’t think they need it (36%) and that they don’t think the benefit of the updated booster is worth it (36%). About one in four (23%) say they have been too busy or have not had time to get the new booster yet.

Most vaccinated Republicans or Republican-leaning independents who haven’t gotten the new booster say that they don’t think they need it (64%) or that its benefits are not worth it (61%).  Among vaccinated Democrats and Democratic-leaning independents who have not gotten the updated booster, the top reason is being too busy (51%).

Relatively small shares of parents of children ages 12-17 (16%) and children ages 5-11 (14%) say their child has already received a bivalent booster. At least half of parents in each age group say either that their child is not vaccinated or that they definitely won’t get their child boosted.

Parents Are Now At Least as Likely to Worry Their Children Will Get RSV or the Flu as COVID-19 

About half (49%) of adults nationally say that they are worried there will be an increase in COVID-19 cases and hospitalizations in the U.S., though just about a third (36%) say they are worried they personally will get seriously sick from the virus. As in the past, Black and Hispanic adults, as well as people over age 65, are among the groups most likely to worry about getting seriously ill.

Amid reports about rising flu and RSV cases, parents are now at least as likely to worry about their children getting sick from those illnesses as from COVID-19. Roughly half of parents say they are at least somewhat worried that their children will get sick from RSV (56%), the flu (51%) and COVID-19 (47%).

Designed and analyzed by public opinion researchers at KFF, the Vaccine Monitor survey was conducted from Nov. 29 – Dec. 8, 2022, online and by telephone among a nationally representative sample of 1,259 adults, in English and in Spanish. The margin of sampling error is plus or minus 4 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and acceptance, information needs, trusted messengers and messages, as well as the public’s experiences with vaccination.

The Centers for Medicare & Medicaid Services (CMS) issued a final rule on October 28, 2022 to implement several changes in Medicare enrollment and eligibility that were included in the Consolidated Appropriations Act of 2021 (CAA). These changes are designed to minimize gaps in coverage for people who sign up for Medicare and improve access to care by shortening the gap between Medicare enrollment and coverage; creating new Special Enrollment Periods for individuals whose coverage would otherwise be delayed due to challenging circumstances, such as a natural disaster; and extending coverage of immunosuppressive drugs for certain beneficiaries with end-stage renal disease (ESRD) who would otherwise lose coverage for these drugs after their kidney transplant.

This brief highlights four key changes related to Medicare enrollment and eligibility under the final rule, and summarizes the estimated impact of these provisions on coverage and costs. These provisions are expected to reduce gaps in coverage for people when they first sign up for Medicare, and have a negligible impact on Medicare spending, according to CMS estimates.

1. The final rule accelerates the start of Medicare coverage for beneficiaries who enroll during the Initial Enrollment Period

Individuals have several opportunities to enroll in Medicare. They can enroll when they first become eligible for Medicare during the Initial Enrollment Period, during the annual General Enrollment Period, or during a Special Enrollment Period. People are generally advised to sign up for Medicare during their Initial Enrollment Period, unless they have group health plan coverage from an employer. Individuals with insurance coverage through the Marketplace or COBRA are also advised to sign up for Medicare during their Initial Enrollment Period. Depending upon when they enroll in Medicare, individuals may face a gap in coverage and late enrollment penalties. Late enrollment penalties are added to a beneficiary’s monthly premium costs for the remainder of their Medicare enrollment. For Medicare Part B, 10% is added to the standard Part B monthly premium for each 12-month period a beneficiary delays enrollment in Part B. The new rule reduces the gaps in coverage between the date of enrollment and coverage during both the Initial Enrollment and General Enrollment Periods, effective January 1, 2023.

Policy prior to January 1, 2023

When an individual is turning 65, their first opportunity to sign up for Medicare is during a 7-month window called the Initial Enrollment Period. This period spans three months before the month of their 65^th birthday, the month of their birthday, and three months after it. When Medicare coverage begins depends on when an individual enrolls during their Initial Enrollment Period. Under the policy in effect prior to January 1, 2023, individuals who enrolled during the last three months of their Initial Enrollment Period could face gaps between signing up and the start of Medicare coverage:

• If an individual signs up for Medicare during any of the first 3 months, their coverage begins the first day of the month they turn 65. If a beneficiary signs up during the month they turn 65, coverage starts the first day of the following month.
• If they sign up 1 month after they become eligible, coverage begins 2 months later, and if they sign up 2 or 3 months after they become eligible, coverage begins 3 months later.

New policy

This rule shortens the time between enrollment and Medicare coverage for individuals who enroll in Medicare during the last three months of their Initial Enrollment Period. Individuals who sign up for Medicare during the last three months of their Initial Enrollment Period will be covered under Medicare the first day of the month following the month in which they enroll.

Examples of how this new policy will affect Medicare coverage

• Mary turned 65 on April 1, 2022, before the new rule took effect. Her 7-month Initial Enrollment Period started three months before her birthday (January) and ended three months after the month she turned 65 (July). Mary signed up for Medicare on July 1, the seventh month of her Initial Enrollment Period. Her Medicare coverage started on October 1, leaving her without Medicare coverage for three months after she enrolled in Medicare, and six months after her 65^th
• Mary’s younger sister, Anne, is turning 65 on April 1, 2023. Under this new rule, if Anne enrolls in Medicare on July 1, 2023, the seventh month of her Initial Enrollment Period, her Medicare coverage will take effect on August 1 (the first day of the month following enrollment), a shorter gap in coverage than her older sister Mary experienced before the final rule took effect.

2. The final rule shortens the gap between enrollment and Medicare coverage for beneficiaries who enroll during the General Enrollment Period

Policy prior to January 1, 2023

If an individual misses their Initial Enrollment Period for Medicare, they can enroll during the General Enrollment Period, which runs from January 1 to March 31 each year. Under the policy in effect until January 1, 2023, for individuals who enrolled at any point during the General Enrollment Period, Medicare coverage would begin on July 1, resulting in up to a six-month gap between Medicare enrollment and the start of coverage.

New policy

Individuals who sign up for Medicare at any point during the General Enrollment Period will be covered under Medicare the first day of the month after they sign up, rather than waiting until July 1.

Examples of how this new policy will affect Medicare coverage

• John’s 65^th birthday was June 15, 2021 (prior to the effective date of the new rule), but he missed his 7-month Initial Enrollment Period, which started three months before his birthday in March 2021 and ended September 2021. His next opportunity to enroll in Medicare was during the next General Enrollment Period, between January 1 and March 31, 2022. John signed up for Medicare during the first week of January, and his Medicare coverage started on July 1, leaving him without Medicare coverage for more than a year after his 65^th birthday and six months after he signed up during the General Enrollment Period.
• John’s brother, Mike, turned 65 on June 15, 2022. He also missed the opportunity to enroll in Medicare during his Initial Enrollment Period and instead plans to sign up during the next General Enrollment period, January-March 2023. If Mike signs up during January, his coverage will begin the following month, on February 1, 2023, rather than on July 1, as it would have under the old policy. The final rule will reduce the number of months people like Mike would have to wait to be covered by Medicare.

3. The final rule establishes new Special Enrollment Periods to reduce gaps in coverage for people who missed their Medicare enrollment period due to certain circumstances

Medicare’s Special Enrollment Periods allow beneficiaries to sign up for Medicare Part B and Premium-Part A or change the type of Medicare coverage they have under certain situations, without being subject to a late enrollment penalty. The time period for enrollment under these Special Enrollment Period, as well as the types of coverage changes that can be made, vary based on circumstances. For example, individuals who did not enroll in Medicare during their Initial Enrollment Period because they received health insurance through a qualified group health plan have an 8-month Special Enrollment Period to sign up for Medicare after they stop working or lose their group health plan coverage. Examples of other circumstances that grant existing Medicare beneficiaries a Special Enrollment Period to change their coverage include moving into or out of a facility (e.g., skilled nursing facility) or if Medicare terminates the beneficiary’s current Medicare Advantage plan. Generally, during a Special Enrollment Period, Medicare coverage, or the change in coverage, begins the first day of the month following enrollment.

Policy prior to January 1, 2023

Prior to the enactment of the Consolidated Appropriations Act of 2021, CMS did not have broad authority to create new Special Enrollment Periods, which potentially created gaps in coverage for individuals seeking to enroll in Medicare who had extenuating circumstances not specified in law (such as those listed above). As a result, some individuals with extenuating circumstances beyond their control, such as someone living in an area struck by a disaster, could miss their Initial Enrollment Period for Medicare and be subject to a late enrollment penalty as a result.

New policy

The Consolidated Appropriations Act of 2021 gives CMS the authority to create new Special Enrollment Periods for individuals who meet certain exceptional conditions. Using this authority, CMS finalized five new Special Enrollment Periods in this final rule that will provide people who missed a Medicare enrollment period because of exceptional circumstances an opportunity to enroll without having to wait for the General Enrollment Period. These Special Enrollment Periods are generally effective for circumstances that occur on or after January 1, 2023, and Medicare coverage will begin the first day of the month following the month of enrollment. For all of these Special Enrollment Periods, individuals will not be subject to a late enrollment penalty.

• Individuals impacted by an emergency or disaster: The rule creates a Special Enrollment Period for individuals who missed an enrollment opportunity because they were impacted by certain government-declared emergencies and disasters. To qualify, an individual must demonstrate that they themselves, their authorized representative, legal guardian, or a person who makes health care decisions on behalf of them, lives in (or lived) in that impacted area. This Special Enrollment Period will begin on the date an emergency or disaster is declared and ends 6 months after the declaration has ended.
• Individuals who experienced a health plan or employer error: This Special Enrollment Period is intended for individuals who did not enroll in Medicare because of misrepresentation by, or incorrect information from their employer, a group health plan, or agents and brokers of health plans. These individuals can enroll in Medicare without penalty starting from the date they notify the Social Security Administration of this error up to 6 months later.
• Formerly incarcerated individuals: This Special Enrollment Period affects: (1) individuals who become newly eligible for Medicare while incarcerated who miss their Initial Enrollment Period while incarcerated; and (2) individuals who were enrolled in Medicare prior to their incarceration, who stop paying their Medicare premiums during incarceration (because Medicare does not cover services during incarceration), and have their Medicare coverage terminated. Both groups of individuals are required to enroll or re-enroll during the General Enrollment Period once they are no longer incarcerated and face a gap in coverage and penalty for late enrollment. This new Special Enrollment Period allows incarcerated individuals who become newly eligible for Medicare to enroll, and current Medicare beneficiaries who drop Medicare coverage while incarcerated to re-enroll, starting the day they’re released and up to 12 months later.
• Individuals who lose Medicaid coverage: This Special Enrollment Period applies to Medicare-eligible individuals who lose Medicaid eligibility on or after January 1, 2023 or the end of the COVID-19 public health emergency (whichever is earlier). Under this Special Enrollment Period, Medicaid enrollees who lose Medicaid eligibility may sign up for Medicare without paying a late enrollment penalty, if they enroll at any time from the date they are notified that their Medicaid eligibility will be terminated up to 6 months after Medicaid eligibility ends. This new Special Enrollment Period was created in response to the expected disenrollment of many Medicaid enrollees who turned 65 during the public health emergency but did not lose their Medicaid coverage on account of requirements in the Families First Coronavirus Response Act. This law required Medicaid programs to keep people continuously enrolled through the end of the month in which the COVID-19 public health emergency ends, in exchange for enhanced federal funding. The public health emergency is currently in effect until January 11, 2023, and is expected to be extended again.
• Other exceptional conditions: Under this rule, if an individual has an extenuating circumstance that caused them to miss a Medicare enrollment period, CMS can grant them a Special Enrollment Period on a case-by-case basis. The duration for this Special Enrollment Period can vary but will be no less than 6 months.

Examples of how these changes will affect Medicare coverage

• Vanessa assists in making health care decisions on behalf of her mother. In August 2023, the governor in Vanessa’s state declares a state of emergency because of a hurricane affecting the county where she lives. Due to the impact of the hurricane, she is unable to help her mother, who lives in a state that was not affected by the hurricane, sign up for Medicare during her Initial Enrollment Period. This new policy will allow Vanessa to help her mom sign up for Medicare up to 6 months after the end of the emergency, reducing the gap between Medicare enrollment and coverage her mother would have otherwise faced, and eliminating any late-enrollment penalties that would otherwise have applied.
• Robert, a 65-year-old man, is enrolled in Medicaid because of his low income. He does not have any dependent children or disabilities and is only eligible for Medicaid through the Affordable Care Act. He turned 65 in June 1, 2022 but did not enroll in Medicare because he was still enrolled in Medicaid. Prior to his 65^th birthday, his state was supposed to send out a letter saying that he would no longer be eligible for Medicaid through the Affordable Care Act, but that he would be eligible for Medicare. However, his state doesn’t send the letter until after the public health emergency ends and Robert has missed his Initial Enrollment Period (March 2022-September 2022). This new rule will allow him to sign up for Medicare from the date he receives the letter notifying him of his Medicaid termination up to 6 months after his Medicaid benefits are terminated, without paying the late enrollment penalty or waiting until the next General Enrollment Period in 2024 to sign up.

4. The final rule extends Medicare coverage of immunosuppressive drugs for certain kidney transplant patients

Adults under the age of 65 with end-stage renal disease (ESRD) qualify for Medicare coverage on the basis of their ESRD diagnosis. Medicare covers all of their covered medical services, not just those related to their ESRD, including kidney transplants, which requires immunosuppressive drugs to prevent the body from rejecting the transplanted kidney. In 2022, there were more than 230,000 Medicare beneficiaries under age 65 with ESRD, including those who qualified on the basis of their ESRD only, representing about 3% of beneficiaries under age 65.

Policy prior to January 1, 2023

When a Medicare beneficiary under the age of 65 with ESRD receives a kidney transplant, their Medicare coverage has ended 36 months after the month in which they received their transplant, unless they’re eligible for Medicare on another basis, such as turning 65 or having a disability. Termination of Medicare coverage can lead to gaps in coverage and adverse health outcomes (e.g., organ rejection) for patients who have received a kidney transplant and continue to need immunosuppressive drugs beyond the point at which their Medicare coverage ends, unless they are able to obtain coverage through another source.

New policy

The final rule allows certain Medicare beneficiaries who have undergone a kidney transplant and would otherwise lose access to Medicare coverage beyond the 36-month post-transplant period to receive coverage only for immunosuppressive drugs after this point through a new Part B benefit referred to as the immunosuppressive drug benefit, or the Part B-ID benefit. Beneficiaries who qualify for the new Part B-ID benefit will not receive coverage for Medicare-covered items and services other than immunosuppressive drugs. The monthly premium for this benefit ($97.10 for 2023) will be less than the standard Part B premium ($164.90 in 2023) and will be higher for those with higher incomes. The standard Part B deductible will apply ($226 in 2023), after which beneficiaries will be responsible for 20% coinsurance for immunosuppressive drugs. There are no late enrollment penalties regardless of when an individual enrolls in the benefit. The rule also allows low-income beneficiaries who are eligible for the Part B-ID benefit to enroll in the Medicare Savings Programs if they qualify, which will help to alleviate the financial burden of costs associated with the new Part B-ID benefit.

If a beneficiary’s Medicare coverage ends before January 1, 2023, they can enroll in the new immunosuppressive drug benefit from October 1, 2022 through December 31, 2022 and coverage will start on January 1, 2023. If a beneficiary’s coverage ends on or after January 1, 2023, they can enroll at any time afterwards, and coverage will begin the month their Part A benefits ends.

Eligible beneficiaries: To be eligible for the new Part B-ID benefit, a beneficiary must be enrolled, or previously enrolled, in Medicare on the basis of their ESRD status, undergo a kidney transplant, and NOT be enrolled, or expect to be enrolled, in certain specific forms of health insurance or other programs that cover immunosuppressive drugs. For example, individuals enrolled in a group health plan, TRICARE for Life program, or a state plan that provides benefits for immunosuppressive drugs will not qualify for this new benefit. Additionally, beneficiaries who become eligible for Medicare based on other reasons (e.g., turning 65, having a disability) will not be eligible for this benefit because they have access to broader Medicare coverage.

Example of how this new Policy will affect Medicare coverage

• Janet is a 35-year-old who became eligible for Medicare because she was diagnosed with ESRD. She received a kidney transplant on January 1, 2019. Her Medicare coverage terminated on January 1, 2022, 36 months after her transplant, because she did not meet other criteria to remain on Medicare. Since then, she has been uninsured and lacked coverage for her immunosuppressive drugs. Under this new policy, Janet will be able to sign up to receive Medicare coverage for her immunosuppressive drugs through this new Part B-ID benefit. She can sign up starting on October 1, 2022, and her coverage will begin January 1, 2023.

What is the estimated impact of the final rule on Medicare enrollment and costs?

These provisions of the final rule are expected to improve gaps in Medicare coverage with minimal impact on Medicare spending. Table 1 provides an overview of CMS’s estimates on the number of individuals impacted, costs to beneficiaries, and costs to Medicare resulting from these changes.

Medicaid is the nation’s single largest health insurance program, and Medicaid enrollment has grown since the start of the COVID-19 pandemic. Early in the pandemic marked what many described as one the most severe economic downturns in United States (US) history. The pandemic-induced recession looked different from historical recessions in a number of ways and was the first downturn with the Affordable Care Act’s (ACA) coverage expansions in place. Of the newly unemployed, many were projected to enroll in Medicaid or take up exchange-based health insurance coverage (though many also were temporarily furloughed and had their employer-sponsored health benefits continued). While the job market has recovered substantially, there have been large layoffs recently at high-profile companies and there are fears that another recession could be on the horizon. This brief reviews what we know about Medicaid enrollment changes during economic downturns, examines unemployment-linked Medicaid enrollments early on in the COVID-19 pandemic, and considers the implications for the unwinding of the national public health emergency (PHE).

How does Medicaid enrollment change during economic downturns?

Medicaid enrollment typically increases during economic downturns. Medicaid is a counter-cyclical program, meaning that more people become eligible and enroll during economic downturns; at the same time, states may face declines in revenues that make it difficult to fund the state share of funding for the program. Historically, increases in the national unemployment rate have been associated with increases in Medicaid enrollment. Medicaid enrollment increased sharply following both the 2001-2002 recession and the Great Recession, and enrollment growth has been a primary driver of total Medicaid spending over the past decade. In the 2007-2009 Great Recession, before the passage of the ACA and expanded Medicaid eligibility for low-income adults, Medicaid enrollment increased by 21% (2.6 million), from 6.8% in 2007 to 8.1% in 2009 among working aged (19-64) adults. Further, rising unemployment during the Great Recession was associated with declining private coverage and increased Medicaid enrollment among persons with private coverage in the previous year.

During the Great Recession, Medicaid enrollment was concentrated in states with more expansive eligibility guidelines based on an analysis that created an index and relied on state upper income limits and categorical eligibility rules. States with more expansive guidelines also experienced smaller increases in cost-related barriers to care associated with rising unemployment in the Great Recession because a larger share of people losing private coverage due to job loss were able to transition to Medicaid. Prior to the implementation of the ACA Medicaid expansion, Medicaid eligibility levels for parents were low (national median eligibility level for parents was 64% of the federal poverty level (FPL) in 2013) and only a small group of states had coverage for childless adults through Section 1115 waivers. Unlike the recent pandemic-induced recession, the MOE requirements tied to the fiscal relief during the Great Recession did not include a continuous enrollment requirement, though states could not make eligibility or enrollment processes more restrictive. The Great Recession also predated the passage of the ACA, which expanded Medicaid eligibility and established tax credits for people buying individual insurance through the ACA marketplace.

How did the ACA and expanding Medicaid make it easier for the unemployed to enroll in Medicaid?

The ACA created new coverage pathways in Medicaid and streamlined Medicaid enrollment  processes, making it easier for the unemployed to enroll in Medicaid. State adoption of the ACA’s Medicaid expansion expanded Medicaid eligibility for nearly all adults up to 138% FPL ($23,030 for a family of three in 2022). The expanded eligibility guidelines made it easier for more people who lost their jobs to qualify for Medicaid because categorical requirements such as parental status were no longer a part of eligibility determination. Following the ACA’s Medicaid expansion, Medicaid enrollment among the unemployed in states that adopted Medicaid expansion increased from 23.5% in 2013 to 44.2% in 2017 (Figure 1). After states expanded Medicaid, becoming unemployed was less of a risk factor for becoming uninsured. According to the Bureau of Labor Statistics, an individual is classified as unemployed if they are currently jobless but are available to work and have actively looked for work in the past 4 weeks.

How did Medicaid enrollment change early in the COVID-19 pandemic?

Medicaid enrollment has increased to record highs during the current COVID-19 PHE. To provide broad fiscal relief to states while preventing coverage losses during the pandemic, Congress passed the Families First Coronavirus Response Act (FFCRA) early in the pandemic to provide a 6.2 percentage point increase in the federal Medicaid match rate (“FMAP”) for states that meet certain “maintenance of eligibility” (MOE) requirements, including a continuous enrollment requirement. The COVID-19 recession had different implications for Medicaid enrollment compared to the Great Recession due to its unique health implications, the MOE continuous enrollment requirement, and the passage of the ACA. While Medicaid enrollment is higher in states that have expanded Medicaid under the ACA, the continuous enrollment requirement during the PHE has resulted in substantial enrollment increases in all states.

Medicaid enrollment increases were concentrated in states with expanded eligibility guidelines in place at the start of the pandemic. An analysis of the Current Population Survey’s Annual Social and Economic Supplement (CPS ASEC) examined coverage trends among adult workers that were employed in 2019 and became newly unemployed in 2020, the first year of the pandemic, compared to workers who were employed in 2019 and remained employed in 2020. Among newly unemployed workers, Medicaid enrollment increased 3.1 percentage points overall, with a larger increase in expansion states (from 17.0% in 2019 to 20.6% in 2020) compared to non-expansion states (from 7.3% in 2019 to 8.9% in 2020) (Figure 2). In addition, uninsurance increased by 1.3 percentage points (from 7.6% in 2019 to 8.9% in 2020) in Medicaid expansion states but increased by 8.4 percentage points (from 17.0% in 2019 to 25.4% in 2020) in non-expansion states among newly unemployed workers. Workers that became unemployed—including temporary layoffs and furloughs—in Medicaid expansion states during the pandemic year were 70% less likely to become uninsured compared to workers that became unemployed in states that did not expand Medicaid.

What to watch looking ahead?

While the PHE end date remains uncertain, it is expected to have significant implications for Medicaid enrollment. Following the end of the PHE and continuous enrollment requirement, Medicaid redeterminations will resume, and individuals may lose Medicaid coverage if they are no longer eligible or are unable to navigate administrative barriers despite remaining eligible. Some individuals who gained Medicaid when they became unemployed may have gained new employment and now have income too high to qualify for Medicaid. They may have access to employer-based health insurance (or already be enrolled in such coverage), or now be eligible for ACA Marketplace coverage with premium assistance. Other individuals may have regained employment but may still qualify for Medicaid if they are employed in a low-wage job. Some individuals may also no longer be in the labor force because of the longer-run effects of COVID-19 infections like long-COVID as well as additional caretaking or childcare responsibilities. To avoid becoming uninsured, individuals will need to transition to other available coverage if they are no longer eligible for Medicaid or renew Medicaid coverage.

While state fiscal conditions have vastly improved since the pandemic began, recent economic developments have raised concerns and heightened uncertainty. States’ longer-term fiscal outlooks remain uncertain due to recent economic turmoil, including rising inflation, the Russian invasion of Ukraine, supply chain issues, along with tapering federal fiscal relief. There have also been warning signs signaling the US could be headed for another recession. The findings described here suggest, in the event of future employment losses, Medicaid can serve as an important safety net to prevent coverage loss following unemployment, and that the safety net is stronger in those states that have expanded Medicaid under the ACA.

A new KFF analysis finds that the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. global HIV/AIDS response and the largest commitment by any nation to address a single disease in history, is associated with improvements in key economic and educational outcomes in countries that received PEPFAR support. Specifically, the program may have helped to grow per capita GDP and reduce the shares of girls and boys who are out of school.

PEPFAR may have a direct economic stimulus effect. The aid program was associated with a 2.1 percentage point increase in the GDP per capita growth rate over the study period, compared to what would have been expected in the absence of the program. The program was also associated with a 9.2 percentage point decline in primary school-age girls not in school. The share of boys of primary school age who were out of school also declined by 8 percentage points in PEPFAR countries.

These findings contribute to existing evidence that PEPFAR, which was not designed as an economic or educational program, has a positive impact on non-health outcomes. The findings also suggest that investments in vertical health programs—those focused on one issue or disease—can have knock-on effects that support broader economic development goals and improvements, which is vital in an era of constrained aid budgets.

For the analysis, researchers studied a data set of 157 low- and middle- income countries. The group included 90 countries that had received PEPFAR support and 67 counties that had received minimal or no PEPFAR support, between 2004 and 2018.

Read the brief, “Assessing PEPFAR’s Impact: Analysis of Economic and Educational Spillover Effects in PEPFAR Countries” and explore the following KFF-produced resources about PEPFAR’s impact:

• Assessing PEPFAR’s Impact: Analysis of Mortality in PEPFAR Countries
• Assessing PEPFAR’s Impact: Analysis of Maternal and Child Health Spillover Effects in PEPFAR Countries
• PEPFAR Policy Resource Hub
• KFF Dashboard: Progress Toward Global HIV Targets in PEPFAR Countries

As winter approaches, a new KFF analysis finds that less than half (45%) of all nursing facility residents and less than a quarter of staff (22%) are up to date with their COVID-19 vaccinations. That is a sharp drop from the 87 percent of nursing facility residents and staff who completed their primary vaccination series.

The U.S. Centers for Disease Control and Prevention (CDC) now defines being up to date as “having received a bivalent booster or having received a final shot of the original vaccines less than two months ago.”

Federal vaccine clinics and health care worker vaccine mandates contributed to high initial vaccination rates among nursing facility residents and staff. But without ongoing federal initiatives, fewer people may stay up to date with their vaccines.

The share of residents who are up to date ranged from 73 percent in South Dakota to 24 percent in Arizona. Among nursing home staff, the share ranged from 48 percent in California to 10 percent in Alabama.

An updated Peterson-KFF Health System Tracker analysis shows the United States experienced a second year of decline in life expectancy in 2021 while other comparably large, wealthy countries saw a rebound in life expectancy since the onset of the COVID-19 pandemic in 2019. Over recent decades, life expectancy has improved by much more in peer nations than it has in the U.S. The COVID-19 pandemic has increased mortality and premature death rates in the U.S. by more than it did in most peer countries, widening a gap that already existed before the pandemic. While the U.S. has the lowest life expectancy among comparable countries, it far outspends its peers on health care. In 2021, the U.S. spent over $4,000 more per capita on health care than the next highest spending country.

If the federal government runs out of money to purchase COVID-19 vaccines, the per-dose price likely would skyrocket and could increase spending on vaccines by billions of dollars a year, a new KFF analysis finds.

To date, the federal government has spent more than $30 billion on COVID-19 vaccines to encourage their development, guarantee a market, and ensure that the public can access them at no charge. The Biden administration has said it can no longer afford to purchase additional doses if Congress does not provide more funds, shifting the burden to the commercial market.

Vaccine makers Pfizer and Moderna have announced that the anticipated commercial price per dose of their vaccines would likely be between $82 and $130 per dose – roughly three to four times what the federal government has paid, according to the KFF analysis.

If payers end up paying those prices for one dose per adult, the analysis estimates that the total cost of purchasing booster shots commercially would run between $6.2 billion and $29.7 billion a year, depending on price and how many people nationally get the vaccine or booster.

Put another way, the federal government could purchase enough bivalent booster shots to serve all adults nationally at its current per-dose price for $7.5 billion, about what it would cost to purchase doses for just a quarter of adults at the higher commercial per-dose price.

While it is possible insurers and other payers could negotiate discounts from the prices suggested by the manufacturers, they will have limited leverage because they will generally be required to cover all recommended vaccines and boosters.

Even after vaccines are purchased commercially, most people with health insurance should still be able to access COVID-19 vaccines without any cost-sharing, and the higher per-dose price would be borne by public and private insurers, including Medicare and Medicaid. For private insurers and their enrollees, these costs could push premiums upward.

People who are uninsured would lose guaranteed access to free COVID-19 vaccines, and the high cost of getting one at the commercial price could discourage some from getting them.