KFF has updated its national analysis of race/ethnicity data of COVID-19 cases and deaths, vaccinations, and treatments as concerns grow over a potential increase in COVID-19 cases during winter and upcoming holiday gatherings and the low take-up of the COVID-19 bivalent booster vaccine among the eligible public.

Despite earlier progress narrowing disparities in COVID-19 vaccination, new disparities have emerged in take-up of boosters and treatment.

Federal data from earlier this month indicates that, among the eligible population, 10% of White people had received a COVID-19 bivalent booster dose, twice the rate of eligible Black (5%) and Hispanic (4%) people and nearly twice as high as for Native Hawaiian or Other Pacific Islander people (6%). Eleven percent of Asian people and 8% of American Indian and Alaskan Native people had received a bivalent booster dose.

The bivalent booster data stands in contrast to the vaccination rates among racial and ethnic groups for at least one dose of the primary COVID-19 vaccine. The rate for a primary COVID-19 vaccine dose among White people stood at 56% earlier this month. The primary vaccine dose rate among Black people lagged at 50%, while other racial and ethnic groups had surpassed the rates among White people. Uptake of at least one dose of the primary COVID-19 vaccine began leveling off across all racial/ethnic groups in late winter 2021.

Racial and ethnic gaps are also found in the data on the treatment of COVID-19. As of mid-2022, among COVID-19 patients aged 20 and older, people of color were less likely to have been treated with the antiviral treatment Paxlovid. While the disparities were found across all age groups, the Paxlovid treatment gap was more evident among adults aged 50 or older and those who are immunocompromised (groups more at risk for serious health outcomes).

For the full analysis including a look at the trends in racial disparities in cases and deaths which have widened and narrowed over the course of the pandemic read, COVID-19 Cases and Deaths, Vaccinations, and Treatments by Race/Ethnicity as of Fall 2022.

As the United States enters its third holiday season navigating a potential increase in COVID-19 cases as well as other respiratory illnesses, federal data from the Centers for Disease Control and Prevention (CDC) show that as of November 9, 2022, 80% of the total population in the United States have received at least one dose of a COVID-19 vaccine and only 10% of eligible individuals have received the updated, bivalent booster that was authorized for use among individuals 5 years of age and older in early Fall 2022. Individuals who have not received any booster dose are at higher risk of infection from the virus, and people who remain unvaccinated continue to be at particularly high risk for severe illness and death.

Over the course of the pandemic, racial disparities in cases and deaths have widened and narrowed. However, overall, Black, Hispanic, and American Indian and Alaska Native (AIAN) people have borne the heaviest health impacts of the pandemic, particularly when adjusting data to account for differences in age by race and ethnicity. While Black and Hispanic people were less likely than their White counterparts to receive a vaccine during the initial phases of the vaccination rollout, these disparities have narrowed over time and reversed for Hispanic people. Despite this progress, a vaccination gap persists for Black people. COVID-19 outpatient treatments, which can mitigate hospitalization and death from COVID-19, are also available. However, early data suggest racial disparities in access to and receipt of these treatments.

This data note presents an update on the status of COVID-19 cases and deaths, vaccinations, and treatments by race/ethnicity as of Fall 2022, based on federal data reported by the Centers for Disease Control and Prevention (CDC).

What is the status of COVID-19 cases and deaths by race/ethnicity?

Racial disparities in COVID-19 cases and deaths have widened and narrowed over the course of the pandemic, but when data are adjusted to account for differences in age by race/ethnicity, they show that AIAN, Black, and Hispanic people have had higher rates of infection and death than White people over most of the course of the pandemic. Early in the pandemic, there were large racial disparities in COVID-19 cases. Disparities narrowed when overall infection rates fell. However, during the surge associated with the Omicron variant in Winter 2022, disparities in cases once again widened with Hispanic (4,341 per 100,000), AIAN (3,818 per 100,000), Black (2,937 per 100,000), and Asian (2,755 per 100,000) people having higher age-adjusted infection rates than White people (2,693 per 100,000) as of January 2022 (Figure 1). Following that surge, infection rates fell in Spring 2022 and disparities have once again narrowed. However, as of September 2022, the age-adjusted COVID-19 infection rates were still highest for Black and Hispanic people (192 per 100,000 for each group), followed by AIAN people at 188 per 100,000. White and Asian people had the lowest infection rates at 164 per 100,000 and 153 per 100,000, respectively. While death rates for most groups of color were substantially higher compared with White people early on in the pandemic, since late Summer 2020, there have been some periods when death rates for White people have been higher than or similar to some groups of color. However, age-adjusted data show that AIAN, Black, and Hispanic people have had higher rates of death compared with White people over most of the pandemic and particularly during surges. For example, as of January 2022, amid the Omicron surge, age-adjusted death rates were higher for Black (37.4 per 100,000), AIAN (34.7 per 100,000), and Hispanic people (29.9 per 100,000) compared with White people (23.5 per 100,000) (Figure 1). Following that surge, disparities narrowed when death rates fell. As of August 2022, age-adjusted death rates were similar for AIAN (4.9 per 100,000), Black (4.4 per 100,000), and White people (4.2 per 100,000) and lower for Hispanic (3.6 per 100,000) and Asian (2.7 per 100,000) people. Despite these fluctuations over time, total cumulative age-adjusted data continue to show that Black, Hispanic, and AIAN people have been at higher risk for COVID-19 cases, hospitalizations, and deaths compared with White people.

What are COVID-19 vaccination and booster patterns by race/ethnicity?

While disparities in COVID-19 vaccinations have narrowed over time and have been reversed for Hispanic people, they persist for Black people. Ongoing KFF analysis shows that at both the federal and state level, there were large gaps in vaccination for Black and Hispanic people in the initial phases of the vaccination rollout, which narrowed over time and eventually reversed for Hispanic people. Despite this progress, a vaccination gap persists for Black people. According to the CDC, overall, 80% of people had received at least one COVID-19 vaccination dose as of November 9, 2022, and race/ethnicity was known for 75% of people who had received at least one dose. Based on those with known race/ethnicity, about half (50%) of Black people had received at least one dose compared with 56% of White people, two-thirds (66%) of Hispanic people, and over seven in ten Native Hawaiian and other Pacific Islander (NHOPI) (70%), Asian (72%), and AIAN (77%) people (Figure 2).

Overall, few people have received the updated bivalent booster vaccine dose, and Black and Hispanic people are about half as likely as White people to have received this booster so far. The updated bivalent boosters protect against both the original virus that causes COVID-19 and the BA.4 and BA.5 Omicron variants. These boosters became available for people ages 12 years and older on September 2, 2022, and for people ages 5-11 years old on October 12, 2022. The CDC recommends that people ages 5 years and older receive one bivalent booster at least 2 months after their last COVID-19 vaccine dose. The CDC reports that, overall, 10% of people over age five have received the updated bivalent booster vaccine dose as of November 9, 2022, with race/ethnicity data available for 88%. Based on those with known race/ethnicity, 11% of eligible Asian and 10% of eligible White people had received a bivalent booster dose, roughly twice the shares of eligible Black (5%) and Hispanic people (4%) (Figure 2). The bivalent booster dose rate was 6% for eligible NHOPI people and 8% for eligible AIAN people.

What are COVID-19 treatment patterns by race/ethnicity?

New data from CDC show racial disparities in receipt of COVID-19 oral antiviral treatments, including Paxlovid, the most widely prescribed antiviral. As of November 2022, there are four COVID-19 outpatient treatments, including: Paxlovid and Lagevrio, oral antivirals that were both approved in December 2021; Veklury, an IV infusion antiviral that was approved in January 2021; and Bebtelovimab a monoclonal antibody that was approved in February 2022. Outpatient COVID-19 treatments are recommended for people who have tested positive for COVID-19 with mild to moderate symptoms and who are at high risk of developing severe illness. Prior KFF analysis pointed to potential disparities in access to COVID-19 treatments for counties with the highest poverty rates and those that are majority Black, Hispanic, and AIAN. Other analyses have documented disparities in monoclonal antibody treatments by race and ethnicity as well as disparities in oral antiviral treatment by zip-code vulnerability. An October 2022 CDC Morbidity and Mortality Weekly Report adds to these findings showing that, through July 2022, people of color were less likely to receive currently available outpatient antiviral COVID-19 treatments compared with their White counterparts. Specifically, between April to July 2022, the percentage of COVID-19 patients aged 20 years and older treated with Paxlovid was lower among Black (21%) and Hispanic (21%) patients than among White (32%) and non-Hispanic (30%) patients, respectively (Figure 3). The shares of AIAN and NHOPI (25%) and Asian (26%) patients receiving prescriptions were also smaller compared to the share of White patients. These disparities were observed across all age groups and were more evident among adults ages 50 and older and immunocompromised patients. Racial and ethnic disparities existed for treatment with other medications, but differences were small given overall low levels of treatment with these other medications.

Discussion

While disparities in cases and deaths have widened and narrowed over the course of the pandemic, age-adjusted data show that AIAN, Black, and Hispanic people have had higher rates of cases and death compared with White people over most of the course of the pandemic and that they have experienced overall higher rates of infection, hospitalization, and death.

Data point to significantly increased risks of COVID-19 illness and death for people who remain unvaccinated or have not received an updated bivalent booster dose. During the initial vaccine rollout, Black and Hispanic people were less likely to receive vaccines than their White counterparts. However, these disparities have narrowed over time and reversed for Hispanic people, though they persist for Black people. Despite this progress in initial vaccination uptake, overall uptake of the updated bivalent booster dose has been slow so far, and there have been racial disparities in receipt of these booster doses, with eligible Black, Hispanic, and NHOPI people about half has likely to have received an updated booster than their White counterparts. Data also point to disparities in receipt of COVID-19 treatments, with patients of color less likely to receive oral antivirals, including Paxlovid, compared to White patients.

Overall, these data show that although the pandemic has contributed to growing awareness and focus on addressing racial disparities, they persist, reflecting the underlying structural inequities that drive them. The findings highlight the importance of a continued focus on equity and efforts to address inequities that leave people of color at increased risk for exposure, illness, and death as well as to close gaps in access to health care, including COVID-19 treatments. Addressing these gaps is of increasing importance as these disparities may be exacerbated when federal funding for COVID-19 vaccines, treatments, and tests runs out and some people may face increased out-of-pocket costs to access these services. Addressing these inequities is key for narrowing the disparate effects of COVID-19 going forward as well as for preventing similar disparities associated with future public health threats.

The Supreme Court’s decision to overturn Roe v. Wade and send the decision to ban or permit abortion back to the states will likely have health implications beyond banning abortion in many states. There have already been reports of clinicians and pharmacists denying women access to medications like methotrexate and misoprostol to manage their chronic conditions, such as autoimmune diseases and gastric ulcers, because the drugs are also used for medication abortions and treatment of ectopic pregnancies. In these reports, pharmacists have denied or delayed filling prescriptions unless specific codes for non-pregnancy related conditions are given. Some providers are also requesting patients take a pregnancy test to confirm a non-pregnant status before they will prescribe the medications. This analysis finds that the majority of those who use these drugs are women who are not pregnant but have diagnoses for other chronic conditions and rely on these medications to manage their health. Consequently, women of reproductive age with chronic conditions will be most impacted by these actions.

Indications for Use of Methotrexate and Misoprostol

Methotrexate is indicated for treatment of rheumatoid arthritis and other autoimmune diseases that disproportionately affect women. The drug works by suppressing the immune system. Additionally, many chemotherapy regimens include methotrexate for treatment of adult and pediatric cancers, such as leukemia and breast cancer, where it works to slow or stop the growth of cancer cells. It also has some off label uses for common conditions like Crohn’s disease, lupus, and eczema. The drug is also a common treatment for ectopic pregnancies where it stops cells from dividing by interfering with the folic acid in your body.

Beyond methotrexate, another drug that may be limited because of its use in pregnancy terminations is misoprostol. Misoprostol is a prostaglandin that causes cervical softening and dilation, as well as uterine contractions. It is frequently used in obstetrics and gynecology for procedures like the medical management of miscarriage, induction of labor, cervical ripening before surgical procedures, and the treatment of postpartum hemorrhage. It is also indicated for reducing the risk of nonsteroidal anti-inflammatory drug (NSAIDs like aspirin and ibuprofen) induced gastric ulcers in patients at high risk of complications from gastric ulcers. In combination with mifepristone, misoprostol can be used to terminate an intrauterine pregnancy through 70 days gestation. Access to methotrexate and misoprostol is essential for patients, especially women, with these cross-cutting conditions. A more detailed version of Table 1 can be found in the Appendix.

Findings

We examined the gender, age, and diagnosis of people with methotrexate and misoprostol prescriptions and injections in claims from the IBM MarketScan Encounter Database in 2019, a database of claims paid on behalf of enrollees of large employer private health plans. We looked at utilization for both men and women enrollees ages 0-64, with a focus on reproductive aged women, ages 15-49, who did not have indication of a pregnancy in the year. The claims used in this analysis only reflect use under the benefit plan and do not include services for which the enrollee did not file a claim such as a medication abortion that was paid for out-of-pocket without using insurance, which could result in an underestimate of individuals using these drugs.

Methotrexate

We find that women make up the majority of people (71%) with a methotrexate prescription in the 2019 IBM MarketScan Encounter Database compared to 29% of methotrexate prescriptions going to men (Figure 1). Over a quarter (29%) of people with a methotrexate prescription are women of reproductive age, ages 18-49, while 39% are women ages 50-64.

Among reproductive-aged women with a methotrexate prescription claim, 92% had no indication of pregnancy in the measurement year (Figure 2). Among those who were not pregnant, over half (55%) of reproductive-aged women with a claim for a methotrexate prescription had a diagnosis code for rheumatoid arthritis at some point during the year. Nearly a third (33%) had a diagnosis for another autoimmune disease we looked at and just over one in five (18%) had a cancer diagnosis at some point in the year (Table 2).

Misoprostol

Among misoprostol prescriptions, 97% are prescribed to women compared to 3% for men. The majority of women using misoprostol are of reproductive age (80%) (Figure 3).

Among reproductive-aged women with misoprostol prescription, 61% had no indication of pregnancy in the year (Figure 4). Over half (52%) of non-pregnant women of reproductive age had a diagnosis for conditions where misoprostol would be indicated for cervical ripening, such as for an IUD insertion, while another one in three (36%) had a diagnosis code for abnormal bleeding (Table 3).

Implications

As abortion bans are implemented in states in the South and Midwest, reproductive-aged women with autoimmune diseases or cancer could see delays or denials in receiving medications like methotrexate and misoprostol, used to manage their chronic conditions. The abortion bans also have implications for the management of a broad range of conditions that impact women. This analysis finds that limitations and barriers to these treatments will have a disproportionate impact on women, beyond limiting the availability of abortions to terminate pregnancies.

Providers and pharmacists in states where abortion is banned could refrain from prescribing or dispensing these drugs out of fear of prosecution. In response to concerns about access to these medications, on July 13, 2022, the U.S. Department of Health and Human Services issued guidance reminding retail pharmacies that as recipients of federal financial assistance, including Medicare and Medicaid payments, that they are prohibited from discriminating based on sex and other bases (i.e., race, color, national origin, age, and disability) under Section 1557 of the Affordable Care Act. The administration’s stance is that decisions to limit access to these medications could be discriminatory based on age, sex, and disability and could violate Section 1557 of the ACA. This is one of the many unanticipated consequences of the Supreme Court decision to overturn Roe v. Wade and states actions to ban abortion.

Appendix

A new KFF analysis finds that women comprise the majority of patients who rely on certain drugs that may be restricted in response to state abortion bans. Following the Supreme Court decision to overturn Roe v. Wade, some women in abortion-banning states have reported that clinicians and pharmacists denied them access to medications like methotrexate and misoprostol that are used to manage chronic conditions but are also used for medication abortions and treatment of ectopic pregnancies.

Clinicians prescribe methotrexate, which is harmful to fetuses and used to treat ectopic pregnancies, to also manage autoimmune diseases including Crohn’s disease and lupus as well as certain cancers. Misoprostol is one of the drugs that is taken as part of a medication abortion typically with mifepristone, and is also prescribed for miscarriage management, to induce labor, and reduce the risk of ulcers caused by medications like aspirin and ibuprofen. 

This analysis used a large claims database of enrollees in large employer plans to look at the gender, age, and common diagnoses of people with methotrexate and misoprostol prescriptions in 2019. Key findings include the following:

• Seven in ten people with a methotrexate prescription were women. Among women of childbearing age (ages 18-49) with methotrexate prescriptions, 92% were not pregnant in the year. Among those who were not pregnant, the vast majority had an autoimmune disease and about one in five had a cancer diagnosis at some point in the year.
• Among women of childbearing age with misoprostol prescriptions, 97% were women and 61% were not pregnant. The majority of non-pregnant women had a diagnosis for which misoprostol would be needed in preparation for a cervical procedure such as intrauterine device (IUD) insertions, while another one in three were diagnosed with abnormal bleeding.

Read “Abortion Bans May Limit Essential Medications for Women with Chronic Conditions” to learn more.

Medicare beneficiaries may choose to receive their Medicare benefits through traditional Medicare or a Medicare Advantage plan offered by a private health insurance company. Over the past 15 years, the share of Medicare beneficiaries enrolled in Medicare Advantage plans has more than doubled, approaching half of the total Medicare population. One reason for the growth in Medicare Advantage enrollment may be that virtually all plans offer extra benefits not available in traditional Medicare, including coverage of vision (eyeglasses and/or eye exams), hearing (exams and/or aids), fitness, and dental services.

Firms that sponsor Medicare Advantage plans have the ability to determine what, if any, extra benefits to offer, and these decisions may be made with the goal of attracting and retaining enrollees. Firm participation in the Medicare Advantage market is robust, with the average Medicare beneficiary able to choose from 43 plans offered by 9 firms in 2023 (similar to 2022). Despite having broad options, enrollment is highly concentrated, with UnitedHealthcare and Humana accounting for more than 40 percent of all Medicare Advantage enrollees since 2015, and a high of 46 percent in 2022.

This analysis examines how the share of enrollees in plans that offer extra benefits varies across firms, based on an analysis of CMS Medicare Advantage plan benefit and enrollment files (for additional information, see Methods box). We focus on variations across firms based on 2022 enrollment, because plan enrollment for 2023 is not yet available. In addition, we provide an overview of how the 2023 plan offerings, by firm, differ from offerings in 2022. We limited the analysis to individual Medicare Advantage plans that are generally available to all beneficiaries for enrollment (which, for example, excludes plans sponsored by employers/unions and special needs plans that are offered to a defined group of beneficiaries). We present findings for the seven firms with the largest market share in 2022, representing more than four-fifths (83%) of Medicare Advantage enrollment – UnitedHealthcare (24%), Humana (20%), Blue Cross Blue Shield (15%), CVS Health (10%), Kaiser Permanente (6%), Centene (5%), and Cigna (2%).

This analysis looks at how many enrollees are in plans that offer various extra benefits but does not examine how the scope of these benefits varies across plans or insurers. Prior KFF analysis documented substantial variation in the scope of dental benefits offered across Medicare Advantage plans, based on a detailed review of each plan’s Evidence of Coverage, that is beyond the scope of this analysis which relies on public data files. Additionally, we do not examine utilization or out-of-pocket spending associated with these extra benefits, because plans are not required to report these data for supplemental benefits.

Share of Medicare Advantage enrollees in plans with extra benefits, by firm

Across the seven largest firms in the Medicare Advantage market that together account for 83% of all enrollees, there is near universal enrollment in plans that offer vision, hearing, fitness, and dental benefits. There is more variation across firms for over-the-counter, remote access technologies, meals, acupuncture and transportation benefits. It is uncommon for plans to offer other benefits, with a relatively small share of enrollees across all firms in plans that offer in-home support services, bathroom safety, Medicare Part B premium rebates, telemonitoring or caregiver support benefits. Figure 1 shows the share of enrollees in plans that offer each of 14 different extra benefits that we examined, by firm, in 2022.

Nearly all enrollees are in Medicare Advantage plans that offer vision, hearing, fitness and dental benefits.

Overall, virtually all Medicare Advantage enrollees are in plans that offer coverage of some vision (99%), hearing (98%), fitness (98%), and/or dental (96%) services. While coverage is nearly universal, there are some small differences across firms.

At least 95 percent of enrollees in plans sponsored by the firms we examined are offered vision, hearing and/or fitness benefits. Across all firms, there is little difference in the share of enrollees in who are offered at least some vision services, such as eye exams and/or eyeglasses, with at least 99 percent of enrollees in a plan that offers this benefit. Hearing and fitness benefits are also nearly universally offered, though a slightly smaller share of Humana enrollees (95%) are in a plan that covers hearing benefits and slightly smaller share of UnitedHealthcare enrollees (96%) are offered fitness benefits, compared to the national average.

The share of enrollees in a plan that offers dental benefits ranges from 90 percent among UnitedHealthcare enrollees to 100 percent for Humana, CVS Health, and Kaiser Permanente enrollees. Coverage of dental services is also nearly universally offered to enrollees in Centene (98%) and Cigna (99%) plans. As noted earlier, prior KFF analysis has documented wide variation in the scope of dental benefits offered by plans, ranging from preventive services exclusively to more comprehensive coverage.

The share of Medicare Advantage enrollees in plans that offer over-the-counter, remote access technologies, meal, acupuncture, and transportation benefits varies more across firms.

Overall, a majority of Medicare Advantage enrollees are in a plan that offers over-the-counter (84%), remote access technologies (72%), or meal (71%) benefits, while a somewhat smaller share are enrolled in plan with acupuncture (45%) or transportation (39%) benefits. Across firms, however, there are notable differences.

Among the two firms with the largest enrollment, a smaller share of UnitedHealthcare than Humana enrollees are in plans that offer over-the-counter, meal, acupuncture and transportation benefits. While UnitedHealthcare has the largest market share (both historically and currently), a smaller share of enrollees in plans sponsored by UnitedHealthcare than Humana (the insurer with the second highest enrollment) are offered over-the-counter (80% vs 97%), meals (60% vs 100%), acupuncture (13% vs 100%), and transportation (26% vs 49%) benefits. The one exception among benefits that vary across firms is remote access technologies, where nearly all enrollees (98%) in a UnitedHealthcare plan are offered expanded telehealth benefits that include remote access technologies, while no Humana enrollees are in a plan that offers this benefit.  

The two firms with the smallest Medicare Advantage market share, Centene and Cigna, offer transportation benefits to the largest share of enrollees. Transportation benefits are offered to 56 percent of Centene enrollees and 62 percent of Cigna enrollees. No other firm offers this benefit to a majority of enrollees, with 49 percent of Humana enrollees, 41 percent of Blue Cross Blue Shield enrollees, 26 percent of UnitedHealthcare enrollees, and just over one fifth of CVS Health (21%) and Kaiser Permanente (22%) enrollees in a plan that offers a transportation benefit.

It is uncommon for Medicare Advantage enrollees to be in plans that offer in-home support services, bathroom safety, Part B rebates, telemonitoring, or caregiver support.

A relatively small share of Medicare Advantage enrollees are in a plan that offers in-home support services (12%), bathroom safety devices (9%), a rebate toward the Part B premium (7%), telemonitoring (4%), or support for caregivers (4%).

Enrollees in Blue Cross Blue Shield plans are enrolled somewhat more often in a plan that offers in-home support services, bathroom safety, telemonitoring, or caregiver support benefits than enrollees in plans sponsored by other firms. Among enrollees in Blue Cross Blue Shield plans, 29 percent are in a plan that offers in-home support services, compared to 23 percent in Centene plans, 12 percent in Cigna plans, 10 percent in Humana plans, 7 percent in Kaiser Permanente plans, and no enrollees in UnitedHealthcare or CVS Health plans. Similarly, 36 percent of Blue Cross Blue Shield enrollees are in a plan that covers bathroom safety devices, while just 7 percent of Cigna enrollees and fewer than 2 percent of enrollees in plans sponsored by other firms are offered this benefit. Telemonitoring and caregiver support benefits are offered exclusively by Blue Cross Blue Shield among the firms examined. Among Blue Cross Blue Shield enrollees, 15 percent are in a plan that offers telemonitoring services and 11 percent are in a plan with caregiver support benefits, while no enrollees in plans sponsored by other firms are offered these benefits.

Across Medicare Advantage firms, a relatively small share of enrollees are in a plan that provides a rebate toward the monthly Medicare Part B premium. Medicare beneficiaries in both traditional Medicare and Medicare Advantage plans are responsible for paying a monthly Medicare Part B premium.  Some plans provide a rebate that reduces the premium as an extra benefit. With the exception of Kaiser Permanente, all firms have at least some enrollees in a plan that provides a rebate towards the Medicare Part B premium. Centene has a larger share than other firms, with 26 percent of enrollees in a plan with this benefit, followed by Humana (11%), Cigna (9%), CVS Health (6%), UnitedHealthcare (4%) and Blue Cross Blue Shield (4%).

Outlook for 2023

The first release of Medicare Advantage plan benefit package data for 2023 show just a few changes in what is being offered with respect to the extra benefits that we examined at the firm level. For example, UnitedHealthcare is offering meal benefits in 83 percent of its plans in 2023, compared to just over half in 2022. Both Humana and Blue Cross Blue Shield have increased the share of plans offering in-home support services (from 4% of plans in 2022 to 11% of plans in 2023 for Humana; from 20% of plans in 2022 to 27% of plans in 2023 for Blue Cross Blue Shield). Cigna is offering caregiver support services in 17 percent of plans after not offering this benefit in any individual plans open for general enrollment in 2022. Finally, Part B premium rebates are included in a somewhat larger share of plans sponsored by Cigna (30% in 2023 compared to 18% in 2022), Humana (22% in 2023 compared to 14% in 2022) and Blue Cross Blue Shield (14% in 2023 compared to 8% in 2022). Together, these changes mean that the share of Medicare Advantage enrollees in plans that offer extra benefits by firm may differ slightly in 2023, but there are unlikely to be large, broad changes.

Discussion

Nearly all enrollees in Medicare Advantage plans sponsored by the seven largest firms in the market are in a plan that offers some vision, hearing, fitness, and/or dental benefits, but other benefits vary widely across firms or are relatively uncommon. This differentiation may represent firm-level strategies to attract and retain enrollees and grow their share of the Medicare Advantage market. Firms may be looking to attract enrollees from their competitors by offering extra benefits that are considered valuable (in part, because they potentially improve health or lower costs), and tailoring those benefits to particular subgroups of beneficiaries.

Plans are able to offer additional benefits, in part because Medicare spends more per enrollee in Medicare Advantage than it spends per person in traditional Medicare. In particular, rebates paid by Medicare to plans (based on the difference between the bid and the benchmark), which are used to fund extra benefits, have increased rapidly in recent years, rising to nearly $2,000 per enrollee on average in 2022. Of that amount, plans are estimated to spend an average of $480 per enrollee on extra benefits overall, including Part B premium rebates. We do not have the data to know how that amount varies across firms, and so we cannot assess specifically whether firms with larger rebates offer more or different extra benefits. It is possible that certain plans keep more of their rebate dollars for profit (subject to meeting medical loss ratio requirements) or allocate more of their rebate dollars towards a lower out-of-pocket cap or reduced cost sharing for Medicare-covered services.

The Centers for Medicare and Medicaid Services (CMS) has said that “Medicare Advantage is a critical part of CMS’ vision to advancing health equity.” The variation in extra benefits across Medicare Advantage plans may have implications for how effective private plans are in this role. Broad differences in benefits could be consistent with the goal if firms are tailoring and providing benefits, such as transportation, to those with the greatest social or medical needs. These differences could also exacerbate disparities if the extra benefits are not sufficiently focused on high-need populations. Plans are not currently required to report information on utilization or costs associated with extra benefits, nor information about the network of providers for extra benefits, in general, or for specific subgroups. Starting with plan year 2023, some cost information will be required as part of the medical loss ratio reports. However, there will continue to be no information about how utilization of extra benefits, and associated spending, varies by race/ethnicity, income, or health status, so it will remain impossible to assess whether, and the extent to which, extra benefits are having an impact on health outcomes for those with the greatest needs.

Medicare Advantage is projected to soon become the main form of Medicare coverage. Understanding the benefits offered to Medicare Advantage enrollees, how they vary across firms, and how they differ from those available to traditional Medicare beneficiaries is important for understanding how growing enrollment in Medicare Advantage plans is redefining what it means to have Medicare coverage, as well as the effects on health equity. As more beneficiaries receive their coverage through a private plan, the variation in extra benefits offered, as well as the scope and generosity of those benefits, means that Medicare coverage could look meaningfully different for different people.

A new KFF analysis finds that fewer than half of employed women ages 18-64 say their employer offers a paid parental leave benefit, such as maternity or paternity leave (43%) or family and medical leave (44%). Access to these workplace benefits varies widely by employment status, income, location, and level of education. Women who work full-time and have higher incomes are more likely than their part-time or low-income counterparts to say their employer offers any paid leave benefits.

During the COVID-19 pandemic, a lack of paid leave benefits has had significant implications for employed women with children, particularly mothers with low incomes. Among working parents, women continue to be the primary caregivers when their children are sick; compared to 19% of working fathers, 56% of working mothers report they are the ones to care for children when they are ill and cannot attend school. A higher share of mothers with low incomes (61%) say they are the ones to care for sick children compared to mothers with higher incomes (53%). Among working mothers who must stay home to care for sick children, 76% of those with low incomes (below 200% of the federal poverty level) report losing pay when they miss work to care for sick children, twice the share of mothers with higher incomes (38%).

These findings come from the 2022 KFF Women’s Health Survey, which examines several topics related to women’s health and well-being. The analysis is based on a nationally representative sample of 5,145 women and 1,225 men ages 18-64. The data presented are based on survey respondents’ self-identified gender as a “woman” or “man.” Non-cisgendered people are included in the survey but are not reported here because of an insufficient sample size.

Additional findings include the following:

• Forty-nine percent of employed women with higher incomes say their employer offers paid family and medical leave compared to 33% of women with lower incomes.
• Seventy-three percent of women who are employed full-time report that their employer offers paid sick leave, compared to 31% who work part-time.
• The share of fathers who say they usually take care of sick children who cannot attend school has doubled in the past two years, rising from 9% in 2020 to 19% in 2022. While the share grew, more than half of mothers (56%) said they take responsibility for the children who must stay home from school because of illness.

Learn more about these 2022 Women’s Health Survey findings in the brief “Workplace Benefits and Family Health Care Responsibilities.”

A new investigation by KFF’s Kaiser Health News (KHN) lays bare the sizeable efforts by private equity investors to take over large and lucrative parts of the U.S health care system in recent years. KHN found that private equity firms have invested nearly $1 trillion through thousands of deals to acquire hospitals and specialized medical practices during the last decade alone.

The deals, many of them unnoticed by federal regulators, typically result in a ratcheting up of providers’ pursuit of profits – and higher prices for patients, lawsuits, and complaints about quality of care.

The investments range widely and include the acquisitions of physician practices, dental clinic management companies, companies that treat autism, drug addiction and other behavioral health care, and ancillary services such as diagnostic and urine testing labs and software for medical billing. Through other deals, companies tied to private equity have come to dominate specialized medical services such as dermatology, gastroenterology, and anesthesiology in certain markets around the country. All of it has come on top of better-publicized takeovers of hospital emergency room staffing firms as well as the buying up of entire rural hospital systems.

Federal regulators have been almost blind to the incursion. KHN found that more than 90 percent of private equity takeovers or investments fell below the $100 million threshold that triggers an antitrust review by the Federal Trade Commission and the Justice Department.

Whistleblowers and injured patients, however, have turned to the courts to press allegations of misconduct or other improper business dealings. KHN found that companies owned or managed by private equity have agreed to pay fines of more than $500 million since 2014 to settle at least 34 lawsuits filed under the False Claims Act. Most of the time, the private equity owners have avoided liability.

The latest story, published today in USA Today, is part of a broader ongoing series, “Patients for Profit: How Private Equity Hijacked Health Care” in which KHN has examined a wide range of private equity’s forays into the health care system. They include the marketing of America’s top-selling abortion pill, the establishment of “obstetric emergency departments” at some hospitals, investments in the booming hospice care industry and even takeovers of funeral homes and cemeteries. The series includes a video primer, “How Private Equity Is Investing in Health Care”.

KHN collaborates with many editorial partners, and media outlets can publish these and other KHN stories at no charge. KHN also will publish the stories on kffhealthnews.org and promote them through its social media platforms. KHN journalists also are available for interviews about their stories. News organizations interested in working with KHN should contact the news service at KHNPartnerships@kff.org, and those interested in helping to expand and improve health journalism around the country should contact KFF at healthjournalism@kff.org.

About KFF and KHN

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis, Polling and Survey Research and Social Impact Media, KHN is one of the four major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

In addition to its devastating health toll, COVID-19 can also lead to significant financial costs for people needing treatment and for public and private payers. This analysis examines the cost of COVID-19 treatment for inpatient care among people with health coverage through large employers.

It finds that in 2020, COVID-19 hospitalizations cost an average of $41,611, including an average out-of-pocket payment of $1,280 for people with large employer coverage. In 2020, many private insurers and employers temporarily waived out-of-pocket costs for COVID-19 treatment (this is generally no longer the case). For COVID-19 hospitalizations with some cost-sharing expense, an average of $1,880 was spent out-of-pocket by individuals with large employer coverage, though COVID-19 hospitalization costs vary widely for patients with private insurance.

This analysis focuses on people with large employer coverage and does not reflect costs for patients with Medicaid or Medicare. At this time, 2020 is the most recent year of available data, and hospitalization and other treatment costs may have changed with the introduction of newer treatments.

The analysis is available through the KFF-Peterson Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.