With intense immigration activity at the U.S.-Mexico border this year and attention focused on the plight of newly arriving migrants, a new KFF analysis finds communities along the border faced an array of socioeconomic challenges and weak health infrastructures well before this year’s surge.

Texas – which has the most counties along the border and is the only border state that has not expanded Medicaid under the Affordable Care Act – stands out as facing the greatest challenges with twice the uninsured rate among both its border county (26%) and non-border county (20%) nonelderly residents compared with California, Arizona, and New Mexico.

A major factor behind Texas’ higher uninsured rates is that 1 in 3 nonelderly adults in border counties lack health insurance. Medicaid expansion for adults could reduce the uninsured rate among the state’s nonelderly adults. However, compared with non-border counties, the border counties in the state have higher shares of noncitizens who may be ineligible for Medicaid.

Texas trails the three other border states in its supply of providers in all counties. California and Texas border counties lag other counties in the states in their supply of four types of health care providers: primary care, obstetrics and gynecology, dental, and emergency medicine.

Texas trails the three other border states in its supply of providers in all counties. California and Texas border counties lag other counties in the states in their supply of four types of health care providers: primary care, obstetrics and gynecology, dental, and emergency medicine.

Texas also stands in contrast to the three other border states in the clear differences between its border and non-border country residents in other socioeconomic indicators, pointing to more systemic issues. Texas border county residents have lower education levels, household incomes, and full-time employment rates than the state’s non-border county residents.

Arizona, California, New Mexico, and Texas have 44 counties along the border with Mexico that are home to 8 million people. People in the four border states generally are more likely to be Hispanic, noncitizen immigrants, poor, and uninsured than those in other parts of the country. Across all four states, the large majority (over 80%) of residents in both border and non-border counties are U.S. citizens, with most being U.S.-born citizens. Health and Health Care in the U.S.-Mexico Border Region reveals further distinctions between and within the four border states. Better understanding the characteristics and needs of residents in these areas may help inform efforts to respond to the recent immigration surge.

With the 2023 Marketplace Open Enrollment now underway in all states, many are focused on the roll out of the so-called “family glitch” fix as one of the new changes to watch in this tenth Marketplace Open Enrollment. Some consumers with access to employer-sponsored family coverage with high premiums will for the first time be able to enroll in Marketplace plans with financial assistance (premium tax credits and cost sharing reductions) that might make this coverage more affordable to them than their employer-sponsor coverage. However, navigating Marketplace eligibility and enrollment requirements is complicated even without the new rules on the family glitch. This Issue Brief looks at some of the challenges consumers can expect to face in deciding whether to take advantage of the family glitch fix.

Affordability and Employer Coverage

Eligibility for premium tax credits in the Marketplace is based on a person’s household income and whether they have an offer of “affordable” employer-sponsored coverage (among other factors). However, for family members of working individuals, affordability until now was based solely on the cost of self-only coverage available to the worker; the added premium for family members was not considered. That interpretation, adopted in 2013, is sometimes called the “family glitch.” In 2022, the average annual premium for employer-sponsored family health insurance is $22,463, while the average cost of self-only coverage is $7,911. Under the “family glitch”, if, for example, an employer had paid the entire premium for workers’ self-only coverage but contributed nothing toward the added cost of enrolling family members, the workers’ family members would nonetheless have been considered to have an affordable offer of employer-sponsored coverage, preventing them from getting financial assistance for Marketplace coverage.

Under new federal regulations published this fall, the worker’s required premium contributions for self-only coverage and for family coverage will be compared to the affordability threshold of 9.12% of household income. If the cost of self-only coverage is affordable, but the cost for family coverage is not, the worker will not be eligible for Marketplace financial assistance, but her family members can apply for this assistance. If employers offer a choice of plans, the lowest cost option with an actuarial value of at least 60% (the ACA “minimum value” standard) is used to evaluate affordability. (An actuarial value of 60% means the plan covers 60% of the cost of covered benefits on average for a typical group of enrollees, with the remainder being paid by patients through deductibles, copays, and coinsurance.)

Individuals determined eligible for Marketplace premium tax credits can also apply for cost sharing reductions if they enroll in a Silver plan and generally have a household income between 100 and 250 percent of the poverty level (between $23,030 and $57,575 for a household of three for 2023). Cost sharing reductions will lower a consumer’s out-of-pocket costs such as deductibles, copayments or coinsurance. The amount of the cost sharing reduction is determined on a sliding scale based on income. Those in cost sharing reduction plans will also have a lower annual out-of-pocket limit than the maximum amount allowed under ACA rules ($9,100 individual and $18,200 family for 2023).

KFF estimated that more than 5.1 million people fell in the ACA family glitch. KFF also estimates that 85% of these people (4.4 million) are currently enrolled through employer-sponsored insurance and are likely spending more for coverage than individuals with similar incomes would pay in premiums for subsidized Marketplace coverage. Consumers affected by the family glitch could be spending on average 15.8% of their income on their employer-based coverage according to one study. By contrast, the ACA affordability threshold for employer coverage in 2023 is 9.12% of income—an individual spending more than 9.12% of their income in premium contributions for her employer coverage is considered to have unaffordable coverage and is eligible for Marketplace subsidies.

Implementing the Family Glitch Fix

Now that the final regulation has been changed and the employee contribution toward family coverage is taken into account to determine affordability, what can consumers expect as they consider enrolling in a Marketplace Plan with financial assistance?

Consumers need information from their employer

One stumbling block for some employees will be the need to seek specific information from their employer before they can even evaluate whether it makes sense to enroll their families in Marketplace coverage with financial assistance. There is no requirement for an employer to provide this information to their employees, putting the onus on employees to try to gather it. To assist consumers in collecting some of this information, the federal exchange has updated its “Employer Coverage Tool,” which employees can take to their employer and request them to provide information about coverage eligibility, cost and minimum value. Consumers can use this tool to complete their Marketplace application. (Table 1)

IRS rules generally require employer-plan participants to select their coverage option before the beginning of the plan year. After that, employers are only required to permit mid-year changes following specific qualifying events. This can make it difficult to coordinate Marketplace enrollment with employer coverage disenrollment. For instance, an employer may have a plan year that does not begin in January (a non-calendar year plan), in which case Marketplace open enrollment would not coincide with the employer’s open enrollment. New and existing IRS guidance give employers the choice (whether they have a calendar year or non-calendar year plan)¹  to allow the employee or household members to revoke their employer coverage and disenroll mid-year if, due to the family glitch fix, they are newly eligible for Marketplace financial assistance. Employers would need to amend their health plans to allow this disenrollment.

Many employers might not know that they must take action to allow employees to revoke coverage in order to take advantage of the glitch fix for their families. While employers do not have to allow this revocation, in most circumstances it would not adversely affect the employer. Allowing a spouse and a dependent to enroll in subsidized Marketplace coverage, for instance, does not cause an employer to violate the ACA’s employer mandate. Some employers may find cost savings in allowing these family members to disenroll since they are no longer covering these family members.

Consumers have complex choices to evaluate

Even if a consumer can get the information that they need in a timely manner, a more affordable premium for Marketplace coverage is only one item to consider in deciding to enroll:

• “Split” families. The glitch fix does not affect the affordability rule for the worker, only for the worker’s household members. If employer coverage is affordable for the employee but not family members, the employee might still stay in her employer coverage, while her dependents enroll in a Marketplace plan. This “split” family scenario means the family will have two plans, with separate (and likely different) deductibles and out-of-pocket limits and different provider networks. Also, an employee could decide to enroll along with her family in Marketplace coverage. However, because the employee would not be eligible for premium tax credits, her share of the family premium would not be subsidized. In addition, if her family would otherwise be eligible for cost sharing reductions, the family members would have to enroll in a separate Silver marketplace plan from the employee under existing cost sharing reduction rules.
• Networks and cost sharing.
  • Differences in plan provider networks. The breadth of provider networks for Marketplace coverage might not be as robust as those in a typical employer plan. Consumers will need to investigate whether they can still see their existing providers in their new Marketplace plan.
  • Differences in cost-sharing: Those not eligible for cost sharing reductions may also find higher deductibles and out-of-pocket maximums then they had in their employer coverage. For example, the average per-person deductible in job-based plans in 2022 was $1,763, compared to $4,753 under the average Marketplace Silver plan that year.

Considerations going forward

CMS has already ramped up outreach to relevant stakeholders to provide training on the family glitch fix. Time will tell whether more is needed to assure that the family glitch fix is implemented so that affected individuals can access this benefit. Easier ways to access information about employer cost and coverage may be one area to evaluate to alleviate the current complexity. As policymakers evaluate how best to make affordable coverage more accessible in our fragmented health coverage system, implementation of the family glitch is one clear area where trained assistance is clearly important to help consumers.

1. Even for some calendar-year employer plans, if the employer’s open enrollment period does not align with the Marketplace open enrollment period or an employee or employer did not take action to revoke coverage prior to January 1, 2023, consumers still might need permission to disenroll in 2023 outside of their employer plan’s open enrollment period.  IRS Notice 2022-41 released in October 2022 only addressed non-calendar year plans, but in early November 2022 the IRS corrected the Notice to include calendar year plans as well. ↩︎

Introduction

The four states (Arizona, California, New Mexico, and Texas) along the U.S.-Mexico border are home to over 78 million people of whom 8 million live in 44 counties that form the border area and border activity is at an all-time high.^1 ,2 ,3  This year, there have been over two million encounters at the U.S.-Mexico border, which is 24% higher than the number of encounters last year. Although migrants and asylum seekers generally have short stays in border communities, this increased activity is leading to growing demands on border processing capacity and border communities that already face health and socioeconomic challenges and to some state governors busing migrants to other states^.4 ,5 ,6 . Understanding of who lives in the region and their experiences, including their health and access to health care, may help inform efforts to address their needs.

Overall, people living in the four border states generally are more likely to be Hispanic and noncitizen immigrants compared to those in other parts of the country. They also are generally more likely to be poor, and uninsured.⁷  This analysis further examines differences between and within border states in sociodemographic characteristics, health coverage and access to care, as well as health outcomes of people living there. It is based on KFF’s analysis of county-level data from the American Community Survey (ACS) five-year data tables, the Health Resources and Services Administration’s Area Health Resource Files (AHRF), the Centers for Disease Control and Prevention’s (CDC) WONDER database, and the Behavioral Risk Factors Surveillance System (BRFSS). Aside from 2020 mortality data from CDC, the most recent reliable available county-level data from these sources are from 2019. All differences described between border and non-border counties and between states in the text are statistically significant at the p<0.05 level. The data included in this brief are from the two years preceding the influx at the U.S.-Mexico border to provide context for the situation in the border region before the recent increase in immigration activity.

The findings show that, across many of the measures examined, Texas fared worse compared to the other border states. Moreover, within Texas, individuals in border counties faced increased challenges compared to those in non-border counties, with particularly low levels of educational attainment and income, higher shares of households with limited English proficiency (LEP) and no computer access, higher uninsured rates, and more limited access to providers. In the other border states, there are smaller differences in these measures between people living in border vs. non-border counties. In contrast to the other border states, Texas has not implemented the Affordable Care Act (ACA) Medicaid expansion to adults, contributing to lower rates of Medicaid coverage and higher uninsured rates compared with the other states, especially in border counties.

While immigration remains a contentious political issue, these findings highlight the potential benefits of providing resources and support to the border region to meet the needs of the growing number of migrants and asylum seekers in the area. Better preparedness, more job opportunities, and a greater allocation of resources to help migrants assimilate in the community may be helpful not only in improving socioeconomic and health outcomes and reducing disparities in border areas, but in improving the economy overall, particularly in these border communities.⁸  Policies that increase opportunities for newly arriving migrants to work, such as reducing the wait time for applying for work authorization, could also reduce overcrowding at migrant shelters.⁹  Although such policies could increase competition for jobs, research has found that immigrants and U.S.-born citizens in the low-skilled workforce usually fill different types of jobs as opposed to competing for the same types of jobs.¹⁰  A separate study found that immigrants in the U.S create more jobs than they take, thereby improving the economic outcomes for U.S.-born workers.¹¹ 

Funding to support organizations providing direct assistance to newly arriving migrants and asylum seekers, funding to support community health workers and Federally Qualified Health Centers in border areas, and funding to address social needs such as poverty and LEP may help improve outcomes in the border region.¹²  Moreover, implementation of the Medicaid expansion in Texas could help to increase overall coverage rates and provide increased financial resources to support health providers and the health care system.

What happens when migrants arrive at the U.S.-Mexico border?

Immigration activity at the border is at an all-time high, with over two million encounters in 2022, a number that is 24% higher than the year before. Historically, the U.S.-Mexico border was primarily used as an entry point by migrants from Mexico, Guatemala, Honduras, and El Salvador; however, migrants from other countries, including Venezuelans, Cubans, and Nicaraguans, accounted for 43% of border encounters in 2022, a 39 percentage point increase since 2017.¹³  Some migrants from European countries like Ukraine have also used the Southwestern border between the U.S. and Mexico to seek entry into the country following political turmoil.¹⁴ 

U.S. Customs and Border Protection (CBP) screens and processes migrants and asylum seekers when they arrive at the border. Based on this screening, individuals may be returned to Mexico under Title 42 or other policies, detained, placed under expedited removal to return to their home country, or, if seeking asylum, released into the U.S. with a notice to appear in court or report for further processing.^15 ,16 

A range of nonprofit organizations help support migrants and asylum-seekers in the border region. Individuals released from custody may seek to reunite with family and friends already living in the U.S., with many traveling on to other areas of the country outside of the border region. However, they typically have very limited or no resources available and often rely on nonprofit organizations for assistance, particularly when they first arrive in the country. While refugees are authorized to work immediately upon arrival to the U.S.,¹⁷  asylum seekers must wait at least 150 days after filing their asylum application to apply for employment authorization and are not eligible to receive employment authorization until at least 180 days post-asylum filing, limiting their opportunities to work.¹⁸  The U.S. Congress recently appropriated $150 million in funding through the Federal Emergency Management Agency to reimburse faith-based, nonprofit, and government organizations providing humanitarian assistance, such as food and housing, to migrants.

Who lives in the U.S.-Mexico border region?

Overall, there are 78 million people living in the four states (Arizona, California, New Mexico and Texas) along the U.S.-Mexico border. Within these four states, there are 44 counties that sit along the border that are home to over 8 million people. Most (32) of these counties are in Texas, while 6 are in New Mexico, 4 are in Arizona, and 2 are in California. These states also include 316 non-border counties, with Texas again accounting for the largest number of these counties (222).

In Arizona, California, and Texas, border county residents are more likely to be Hispanic as compared with those in non-border counties (Figure 1). In Arizona, California, and New Mexico, over half of residents in border counties are Hispanic, while this share rises to over three-quarters (76%) in Texas. In contrast, Hispanic people make up less than a quarter of residents in non-border counties in Arizona (23%) and less than a third of non-border county residents in Texas (29%) and California (30%), while they account for closer to half of people in non-border counties in New Mexico (47%). The age distribution of people living in border and non-border counties is largely similar across all four states.

In Arizona and Texas, border counties include higher shares of noncitizens compared with non-border counties, but the vast majority of residents in both types of counties in all four states are U.S.-born citizens. In Arizona and Texas, roughly one in ten people in border counties is a noncitizen, which is higher than non-border counties. The share is slightly higher in California border counties (13%) and lower in New Mexico border counties (6%) with no statistically significant difference between border and non-border counties in these states. Across all four states, the large majority (over 80%) of residents in both border and non-border counties are U.S. citizens, with most being U.S.-born citizens.

In Texas, border county residents have lower levels of educational attainment, full-time employment, and household incomes than their counterparts in non-border counties. (Figure 2). In Texas, the proportion of border county residents with less than a high school education is nearly twice as high as non-border county residents (30% vs. 17%). In contrast, the share of residents with less than a high school education is similar across border and non-border counties in the other three states. Regarding employment, the share of individuals living in border counties who are full-time workers is similar to the share in non-border counties in Arizona (48% vs. 45%), California (45% vs. 47%), and New Mexico (43% vs. 48%). However, the share of people in border counties who are full-time workers is lower than the share in non-border counties in Texas (49% vs. 55%), which has the highest share of full-time workers in non-border counties across the four states. Consistent with these findings, households in border counties in Texas are more likely than households in non-border counties to have incomes less than $25,000 (25% vs. 16%) and less likely to have incomes at or above $100,000 (18% vs. 28%). In contrast, the income distribution in Arizona, California, and New Mexico is similar between border and non-border counties. In California, over a third of residents in both border and non-border counties has household income of at least $100,000, which is higher compared to the other three states.

In California and Texas, households in border counties are more likely than those in non-border counties to face language barriers (Figure 3). Texas and California have the highest shares of households with limited English proficiency (LEP) in border counties (17% and 15%, respectively), which are over four and three times higher than the shares in their non-border counties (4% and 6%, respectively). In Arizona and New Mexico there are no statistically significant differences between border and non-border counties in the share of households with LEP. Access to computers and broadband access is generally similar between border and non-border counties in Arizona, California, and New Mexico. However, in Texas, nearly a quarter (23%) of households in border counties lack computer access compared to 14% of those in non-border counties. Texas also has the highest shares of households reporting no broadband access in both border and non-border counties across the four states, with lower broadband access in non-border than border counties (22% without broadband access vs. 18% without broadband access).

What is the status of health and health care in the border region?

Uninsured rates among nonelderly residents in both border and non-border counties in Texas are at least twice as high as the other three border states, and nonelderly residents in its border counties are more likely to be uninsured than those in its non-border counties (26% vs. 20%) (Figure 4). In Texas, private coverage rates are lower in border counties than non-border counties. While the Medicaid coverage rate is higher in border counties than non-border counties, it does not fully offset the difference in private coverage leading to the higher uninsured rate for its residents in border counties. In the other three border states, there are no significant differences in insurance coverage patterns between border and non-border counties. The higher uninsured rates in Texas are mostly driven by higher uninsured rates for nonelderly adults, which are particularly high in border counties, where one in three adults lacked coverage. Children in Texas also have higher uninsured rates compared to the other border states, but there is little difference in uninsured rates for children in border vs. non-border counties.

In contrast to the other border states, Texas has not implemented the ACA Medicaid expansion to lower-income adults, contributing to its lower rates of Medicaid coverage and higher uninsured rates compared to the other states. Overall, over 770,000 poor adults are in the Medicaid coverage gap in Texas, accounting for over a third of all adults in the gap nationwide.¹⁹  As noted, in Texas, border county residents have lower levels of full-time employment and household incomes than their counterparts in non-border counties, which may contribute to the lower rates of private coverage in the border counties. While Medicaid coverage helps offset some of this difference, border counties also include higher shares of noncitizens compared with non-border counties, who may face eligibility restrictions for Medicaid. Specifically, those who are undocumented are not eligible to enroll in Medicaid or CHIP or to purchase coverage through the Marketplaces.

In California and Texas, border counties have a more limited supply of certain health care providers than non-border counties. Moreover, Texas has more limited availability of all four types of providers examined in both border and non-border counties compared with the other three states. In Arizona and New Mexico, the supply of providers between border and non-border counties varies based on provider type (Figure 5). For example, Arizona has fewer dentists per 100,000 people in border counties vs. non-border counties (45.3 vs. 55.1) but has more primary care providers per 100,000 in border counties vs. non-border counties (59.3 vs. 49.3).

Adults in Texas border counties are more likely to report poor physical health compared to non-border counties. In Texas border counties, one-third of adults report being in fair or poor health as compared to roughly one-quarter in border and non-border counties in the other border states (Figure 6).There is limited variation in the share reporting 14 or more poor physical or mental health days in a month across border and non-border counties in the four states, however, more adults reported 14 or more poor mental health days in Texas as compared to the other three states.

California, New Mexico, and Texas had higher rates of COVID-19 deaths in border counties vs. non-border counties overall, with the largest difference in Texas, where the border county death rate was nearly twice as high as the rate for non-border counties (161.2 vs. 83.6 per 100,000) (Figure 7). These differences are primarily driven by a higher COVID-19 death rate among Hispanic people in border counties vs. non-border counties. Across the four states, Texas had the highest death rate among Hispanic people. Moreover, within Texas, the death rate among Hispanic people was over 1.5 times higher in border counties than in non-border counties (290.9 vs. 167.1 per 100,000). The death rate for White people in Texas border counties was also higher than their counterparts in non-border counties (89.5 vs. 67.2).

Implications

With the recent surge in immigration activity at the border, it is helpful to better understand who lives in the region and their experiences, including their health and access to health care. Overall, people in the four states along the U.S.-Mexico border are more likely to be Hispanic, noncitizen immigrants, poor, and uninsured than people in other areas of the country. This analysis reveals further distinctions between and within these four states. It shows that, across many of the measures examined, Texas fared worse compared to the other border states. Moreover, within Texas, individuals in border counties fare worse across many examined measures compared to those in non-border counties, with particularly low levels of educational attainment and income, higher shares of households with LEP and no computer access, higher uninsured rates, and limited access to providers. In the other border states, there are smaller differences between people living in border vs. non-border counties.

In contrast to the other border states, Texas has not implemented the ACA Medicaid expansion to adults, contributing to lower rates of Medicaid coverage and higher uninsured rates. These differences are particularly pronounced in its border counties, where over a quarter of nonelderly residents, including one in three nonelderly adults, lacked health coverage. These high uninsured rates coupled with more limited availability of providers, particularly in border counties, likely contribute to challenges accessing health care and strains on safety-net providers, which are likely exacerbated by increased social and economic challenges in these areas.

Overall, these findings highlight the potential benefits of providing resources and support to the border region to meet the needs of the growing number of migrants and asylum seekers in the area. Better preparedness, more job opportunities, and a greater allocation of resources to help migrants assimilate in the community may be helpful not only in improving socioeconomic and health outcomes and reducing disparities in border areas, but in improving the economy overall, particularly in these border communities. Policies that increase opportunities for newly arriving migrants to work, such as reducing the wait time for applying for work authorization, could also reduce overcrowding at migrant shelters. Funding to support organizations providing direct assistance to newly arriving migrants and asylum seekers, funding to support community health workers and Federally Qualified Health Centers in border areas, and funding to address social needs such as poverty and LEP may help improve outcomes in the border region. Moreover, implementation of the Medicaid expansion in Texas could help to increase overall coverage rates and provide increased financial resources to support health providers and the health care system. Immigration remains a contentious political issue, and there are other competing demands for public dollars, but this analysis shows particularly acute health and social needs along the U.S.-Mexico border.

1. U.S. Census Bureau, “Quick Facts”, https://www.census.gov/quickfacts, accessed November 14, 2022. ↩︎
2. U.S. Census Bureau, “County Population Totals: 2020-2021”, https://www.census.gov/data/tables/time-series/demo/popest/2020s-counties-total.html, accessed November 14, 2022. ↩︎
3. U.S. Customs and Border Protection (2022), “Southwest Land Border Encounters”, https://www.cbp.gov/newsroom/stats/southwest-land-border-encounters, accessed October 20, 2022. ↩︎
4. Pew Charitable Trusts (2022), “Minus the Politics, Migrants Often Use Buses, Planes to Reach Shelter”, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2022/10/04/minus-the-politics-migrants-often-use-buses-planes-to-reach-shelter, accessed October 26, 2022. ↩︎
5. National Public Radio (2022), “A dramatic shift at the border as migrants converge on a remote corner of South Texas” https://www.npr.org/2022/09/23/1124561261/a-dramatic-shift-at-the-border-as-migrants-converge-on-a-remote-corner-of-south-, accessed September 23, 2022. ↩︎
6. Migration Policy Institute (2022), “Busing and Flights of Migrants by GOP Governors Mark a New Twist in State Intervention on Immigration”, https://www.migrationpolicy.org/article/migrant-asylum-seeker-busing, accessed October 26, 2022. ↩︎
7. Kaiser Family Foundation (KFF), “State Health Facts”, https://modern.kff.org/statedata/, accessed October 28, 2022. ↩︎
8. The Brookings Institution (2022), “Who are the 1 million missing workers that could solve America’s labor shortages?”, https://www.brookings.edu/blog/up-front/2022/07/14/who-are-the-1-million-missing-workers-that-could-solve-americas-labor-shortages/, accessed October 26, 2022. ↩︎
9. Press Herald (2022), “Rep. Pingree submits bill to shorten asylum seekers’ wait time for work authorization”, https://www.pressherald.com/2022/02/11/pingree-introduces-bill-to-shorten-waiting-period-for-asylum-seeker-work-authorization/, accessed October 26, 2022. ↩︎
10. Urban Institute (2015), “Immigrants and native workers compete for different low-skilled jobs”, https://www.urban.org/urban-wire/immigrant-and-native-workers-compete-different-low-skilled-jobs, accessed November 14, 2022. ↩︎
11. Azoulay, Pierre, Benjamin F. Jones, J. Daniel Kim, and Javier Miranda. 2022. "Immigration and Entrepreneurship in the United States." American Economic Review: Insights, 4 (1): 71-88. ↩︎
12. Rural Health Information Hub (2019), “Rural Border Health”, https://www.ruralhealthinfo.org/topics/border-health, accessed October 21, 2022. ↩︎
13. Migration Policy Institute (2022), “Record-Breaking Migrant Encounters at the U.S.-Mexico Border Overlook the Bigger Story”, https://www.migrationpolicy.org/news/2022-record-migrant-encounters-us-mexico-border, accessed October 26, 2022. ↩︎
14. National Public Radio (2022), “Thousands of Ukrainian refugees arrive at U.S.-Mexico Border”, https://www.npr.org/2022/04/08/1091769484/hundreds-of-ukrainian-refugees-at-the-u-s-mexico-border-hoping-for-asylum, accessed September 23, 2022. ↩︎
15. Kaiser Family Foundation (KFF) (2022), “Title 42 and its Impact on Migrant Families”, https://modern.kff.org/racial-equity-and-health-policy/issue-brief/title-42-and-its-impact-on-migrant-families/, accessed October 26, 2022. ↩︎
16. U.S. Citizenship and Immigration Services (2022), “Asylum”, https://www.uscis.gov/humanitarian/refugees-and-asylum/asylum, accessed October 21, 2022. ↩︎
17. U.S. Citizenship and Immigration Services (2022), “Refugees”, https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees, accessed October 26, 2022. ↩︎
18. U.S. Citizenship and Immigration Services (2022), “USCIS Stopped Applying June 2020 Rules Pursuant to Court Order in Asylumworks v. Mayorkas”, https://www.uscis.gov/laws-and-policy/other-resources/class-action-settlement-notices-and-agreements/uscis-stopped-applying-june-2020-rules-pursuant-to-court-order-in-asylumworks-v-mayorkas#:~:text=You%20may%20apply%20for%20employment,you%20file%20your%20asylum%20application., accessed October 21, 2022. ↩︎
19. Kaiser Family Foundation (KFF) (2021), “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid”, https://modern.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/, accessed October 26, 2022. ↩︎

The Medicare open enrollment period that runs from October 15 to December 7 each year is an opportunity for Medicare beneficiaries in traditional Medicare and Medicare Advantage to evaluate their current coverage, compare plans, and decide whether to make a change for the coming year. Beneficiaries can compare Medicare Advantage plans, mainly HMOs and PPOs, which provide all Medicare-covered benefits, typically including Part D drug coverage, and may offer other benefits such as vision, dental, and hearing benefits. Beneficiaries can also compare Part D stand-alone prescription drug plans, which add drug coverage to traditional Medicare. Costs and coverage can vary from one plan to another and can change from one year to the next.

For coverage in 2023, the typical beneficiary has close to 70 different Medicare private plan options, consisting of 43 Medicare Advantage plans, including 35 with Part D drug coverage and 8 without, and 24 Part D stand-alone drug plans. This total represents two-thirds more plan options than the typical beneficiary had six years ago, an increase driven by a substantial expansion of Medicare Advantage plan offerings.

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.”