The current MPX outbreak in U.S. appears to be slowing down, following its emergence in May and rapid acceleration in June, with most cases having been reported among gay and bisexual men and other men who have sex with men. Cases peaked in August and have recently begun to decline, largely attributed to the deployment of MPX vaccines and to behavior change among those at higher risk. However, disparities in cases persist among Black and Hispanic people, a pattern also seen with HIV and COVID-19. Indeed, new cases among Black people began to exceed those among White people by early August and, while also trending down, have remained consistently higher. Moreover, although Black and Hispanic people account for a disproportionate share of cases relative to their share of the population, they account for a smaller share of vaccinations, which could pose challenges to addressing MPX in these communities moving forward. Finally, ongoing data limitations may hinder the public health response and efforts to mitigate these disparities.

This analysis examines MPX cases and vaccinations by race/ethnicity based on national data obtained from the Centers for Disease Control and Prevention (CDC). Data on race/ethnicity of people with MPX were available for 68% of cases reported as of September 23 (16,847 of 24,846 cases) in all 50 states, the District of Columbia, and Puerto Rico. Data on race/ethnicity of people who have received a first dose of the two-dose JYNNEOS MPX vaccine were available for 91% of vaccinations reported as of September 27 by 51 jurisdictions (526,692 of 576,420 doses). We find that:

MPX case rates among Black people are over five times those of White people (14.4 vs. 2.6 per 100,000) (Figure 1). Native Hawaiian and Other Pacific Islander (NHOPI) and Hispanic people also have significantly higher rates of reported MPX cases at 10.0 and 8.3 per 100,000, respectively. Rates are lower and similar for Asian (3.0 per 100,000), American Indian and Alaska Native (AIAN) (2.8 per 100,000), and White (2.6 per 100,000) people.

Overall, Black people account for the largest share of MPX cases, and both Black and Hispanic people account for larger shares of cases compared with their shares of the population (Figure 2). Of those with known race/ethnicity, 70% or 11,820 of cases are among people of color, while people of color account for 40% of the U.S. population. Black people account for more than a third (35% or 5,847) of cases, which is almost three times their share of the U.S. population (12%). Hispanic people account for 30% or 4,996 of cases, which is 1.6 times their share of the U.S. population (19%). By contrast, White people account for 30% or 5,027 of cases and 60% of the U.S. population. Asian people represent 3% or 549 of cases, which is smaller than their share of the population. Less than 1% or 117 of reported cases with available race/ethnicity data were among AIAN or NHOPI people, while the remaining 2% or 311 of cases were among individuals reporting other or multiple races.

By late summer 2022, the number of new MPX cases among Black and Hispanic people surpassed the number among White people. Based on the 7-day rolling average of newly reported cases with race/ethnicity data, the number of new cases among Black people first surpassed those among White people on July 21, and, after some fluctuation, has remained consistently higher since August 2 (Figure 3). The 7-day rolling average of new cases reported among Hispanic people surpassed that among White people on August 3 and remained higher until recently. The average number of new cases among Asian, AIAN, and NHOPI people has remained lower than the number among White people over the period examined. While new cases have begun to fall across all racial and ethnic groups, they remain highest among Black people; new cases among Hispanic people have fallen below those among White people.

Black and Hispanic people have received smaller shares of MPX vaccines compared to their shares of cases. The deployment of effective MPX vaccines has been identified as one key factor contributing to the decline in cases. As of September 27, over half (51%) of MPX first doses of vaccinations have gone to White people, although they represent 30% of reported cases (Figure 2). In contrast, despite accounting for more than a third of cases (35%), only 13% of first doses administered went to Black people. Similarly, 22% of first doses have gone to Hispanic people, while they account for 30% of cases. The lower shares of vaccinations among these groups may in part explain why they have had higher numbers of new cases and complicate efforts to address disparities moving forward.

Ongoing data limitations may hinder the public health response and efforts to mitigate these disparities. The ability to monitor MPX cases and vaccination by race/ethnicity provides key measures of where disparities exist and could help to focus outreach and resources to hard hit communities. However, data limitations make tracking these demographic patterns challenging. These include missing race/ethnicity case data for almost a third (32%) of reported cases and for one in ten vaccinations (9%) the lack of available data to allow for intersectional analysis of disparities across multiple factors, such as by race/ethnicity, sex, gender identity, and risk; and the lack of state-level demographic data. Moreover, national-level data by risk factor are increasingly missing from jurisdictional reports to CDC, limiting an assessment of risk for current cases.

Together, these data indicate that there are significant disparities in MPX cases among Black, NHOPI, and Hispanic people, with case rates among Black people more than five times greater than those among White people. Moreover, to date, Black and Hispanic people have received lower shares of vaccinations compared to their shares of MPX cases. These disparities likely result from multiple factors, including structural barriers, which complicate access to information and interventions and contribute to more limited access to health care overall; stigma and homophobia, which may make some reluctant to seek care or be offered services; and data challenges which may delay or obscure recognition of the full scope of the impact of MPX among people of color. These findings highlight the importance of centering intersectional equity in MPX response efforts, including prevention, testing, and treatment. As has been seen with HIV and COVID-19, underlying structural inequities place people of color at increased risk for public health threats and focused efforts will be key to minimizing and preventing further disparities going forward. While the federal government has begun piloting efforts to reach communities of color with MPX vaccines in order to address disparities, it is unclear if such efforts will be enough to stave off further disproportionate impact, and much will also depend on what state and local jurisdictions do.

KFF’s Kaiser Health News (KHN) and the radio program “This American Life” together have won a Loeb Award in the audio category for a deeply reported account of the threats and hate targeted at local public health officials during the covid-19 pandemic.

KHN’s coverage of public health issues will remain a priority beat in the newsroom long after the threat of covid fades. KFF will announce new partnerships and public health reporting plans in the coming months.

In ‘We’re Coming for You’: For Public Health Officials, a Year of Threats and Menace”, the two news organizations chronicled how health officers became the face of local government authority, illustrating through the lens of California’s Santa Cruz county how they became the targets of rage and resentment from loose-knit militia and white nationalist groups. The county, though widely viewed as liberal and progressive, saw an escalating succession of threats, capped by the cold-blooded killing of a sheriff’s deputy, that upended the lives of health leaders trying to navigate the covid response.

KHN senior correspondent Anna Maria Barry-Jester told the story of Dr. Gail Newel, Santa Cruz County’s health officer, and her boss, Mimi Hall, the county’s health services director, who soldiered on as debate over legitimate covid-related public health orders devolved into vitriol and intimidation. Their daily routines changed to incorporate security patrols, surveillance cameras and, in some cases, personal firearms.

This was KHN’s first collaboration with “This American Life.” Listen to the “This American Life” audio story, entitled “The Herd,” here. And read KHN’s companion digital story here.

The Loeb Awards, established in 1957 and considered the most prestigious honor in business and financial journalism, are administered by The G. and R. Loeb Foundation Inc. and the University of California at Los Angeles’s Anderson School of Management. This is KHN’s third Loeb Award.

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.

About This American Life

This American Life is an award-winning weekly public radio program and podcast hosted by Ira Glass. It is heard by 2 million listeners each week on over 500 public radio stations in the U.S., with another 2.8 million people downloading each episode as a podcast. The show is produced in collaboration with WBEZ Chicago and delivered to stations by PRX, Public Radio Exchange.

This fact sheet does not reflect recent changes that have been implemented by the Trump administration, including a foreign aid review and restructuring. For more information, see KFF’s Overview of President Trump’s Executive Actions on Global Health.

Key Facts

• Polio, a highly infectious and sometimes deadly disease that has plagued the world since ancient times, is now at very low levels, with 6 reported cases of wild poliovirus (WPV) in 2021.
• Since eradication efforts began in earnest 30 years ago (when cases numbered 350,000 annually), polio has been eliminated in more than 120 countries and remains endemic in only two.
• A global push for polio eradication by 2026 is underway. If polio is eradicated, it would only be the second time in history that a disease affecting humans has been eradicated. Early in the COVID-19 pandemic, global polio immunization campaigns were paused for a few months but then were resumed, and polio efforts now may be benefitting from heightened community awareness of the benefits of vaccinations due to the COVID-19 vaccination effort.
• Eventually, polio efforts will transition from using oral poliovirus vaccine (OPV) to using only inactivated poliovirus vaccine (IPV) through a phased process over several years, which will help to eliminate outbreaks caused by circulating vaccine-derived polioviruses (cVDPV). Type 2 cVDPV (cVDPV2) represents the vast majority of cVDPV cases worldwide, including the case recently found in the United States, and is a major challenge to achieving polio eradication.
• The U.S. government (U.S.) has been engaged in efforts to address polio for decades, as a partner in and the second largest donor to the Global Polio Eradication Initiative and as a supporter of developing countries’ efforts.
• U.S. funding for polio is $253 million in FY 2022, up from $134 million in FY 2009.

Global Situation

Polio, a highly infectious and sometimes deadly disease that has plagued the world since ancient times,¹  is now at very low levels, and today, global polio efforts are focused on sustaining efforts to eradicate the disease, which have already resulted in a 99.9% reduction in cases since 1988 (see Table 1). Progress against the disease has been made possible by the development and expanded use of effective vaccines, particularly the more easily administered and less expensive oral poliovirus vaccine, and mass immunization campaigns (see below).

A global push for polio eradication is underway.⁴  If polio is eradicated, it would only be the second time in history that a disease affecting humans has been eradicated (smallpox being the other),⁵  a “once-in-a-generation opportunity for global public health.”⁶ 

History

The development of effective vaccines against polio in the 1950s and 1960s led to their widespread use in many industrialized countries, including the United States, and resulted in the elimination of polio in a number of countries. These early successes suggested that global polio eradication (through the use of mass immunization campaigns) might be achievable.⁷  Soon thereafter, in 1988, the World Health Assembly launched the Global Polio Eradication Initiative (GPEI) – constituted as a public-private partnership led by national governments and spearheaded by the World Health Organization (WHO), Rotary International, the U.S. Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF), and the Bill & Melinda Gates Foundation – to work toward this goal.⁸  GPEI partners have invested approximately $19 billion globally in eradicating the disease.⁹ 

In 2012, the World Health Assembly stated that successfully eradicating polio was a “programmatic emergency for global public health,” given ongoing challenges that threatened the gains that had already been made.¹⁰  More recently, in 2014, WHO declared the continued spread of polio a “public health emergency of international concern” due to the global risks posed by the disease; under the International Health Regulations, this declaration required certain countries to heighten their efforts against polio.¹¹  See the KFF fact sheet on WHO.

Impact

Since 1988, the global effort to interrupt transmission of wild poliovirus (WPV, the cause of polio) has seen successes and setbacks. The virus was gradually eliminated across the Americas (in 1994), the Western Pacific (in 2000), Europe (in 2002), South-East Asia (in 2014), and Africa (in 2020).¹²  Still, in other regions, it remained endemic in some countries. Today, the virus continues to be endemic in two countries: Afghanistan and Pakistan (see Table 1). In addition, polio-free countries must remain vigilant to prevent reintroduction of the virus, which can lead to re-establishment of polio transmission.¹³  Importation of the virus from another country is a continuing threat, with countries stretching across west Africa to central Africa to the Horn of Africa most often affected.¹⁴ 

Current efforts in endemic countries focus on interrupting transmission of the remaining type of wild poliovirus: WPV 1. (The other WPV types, WPV 2 and WPV 3, have been declared eradicated as of 2015 and 2019, respectively.¹⁵ ) In 1 of 200 persons infected with wild poliovirus, permanent paralysis (usually of the legs) occurs, and of these, 5-10% die when paralysis affects the respiratory muscles.¹⁶  The disease is most prevalent among underserved populations in developing countries, typically striking children under five who live in poverty and who lack access to clean water, good sanitation, immunization and other health services. Young children are more vulnerable to and disproportionately affected by polio.¹⁷ 

Interventions

Several strategies are important in preventing the spread of polio:

• ensuring high levels of routine immunization coverage (greater than 80%) among infants (children under one year old), including multiple doses of oral poliovirus vaccine (OPV) and/or inactivated polio vaccine (IPV) (see Box 1);
• mass immunization campaigns through National Immunization Day campaigns or supplementary immunization activities (SIAs);
• heightened poliovirus surveillance and lab capacity to detect new cases and importations;¹⁸  and
• targeted campaigns (“mop-up” campaigns) to respond to outbreaks in specific areas the virus is known or suspected to be circulating.¹⁹ 

Mass immunization, which is designed to complement the individual protection provided by routine immunization and build herd immunity,²⁰  is intended to immunize children under five who have not been immunized or may only be partially protected, while also boosting the immunity of children who have been immunized. It is only through high levels of sustained herd immunity that virus transmission will stop. A large cadre of volunteers vaccinates thousands, and often millions, of children during these campaigns.

These four main strategies are supported by health worker training, communication campaigns, community outreach, engagement with community and religious leaders, new technological and scientific advances, technical assistance, sharing of best practices, and vaccine production efforts.

Vaccine Transition

To fully achieve eradication, polio vaccination efforts worldwide will eventually transition from OPV to IPV through a phased process over several years. Replacing OPV with IPV will help eliminate outbreaks caused by circulating vaccine-derived polioviruses (cVDPV) (see Table 1) and other VDPV, since OPV includes live, weakened poliovirus (which in very rare cases can mutate and then circulate in communities with low vaccination coverage), while IPV does not.²¹ 

Vaccine Switch. A key step in this transition from OPV to IPV was making a “switch” from OPV that targets all three types of wild poliovirus to OPV that targets the remaining two types of wild poliovirus (WPV 1 and WPV 3). For most countries, this switch occurred beginning in April 2016, preceded by efforts to introduce at least one dose of IPV into routine immunizations in order to maintain immunity against WPV 2.²²  Still, type 2 cVDPV (cVDPV2) represents the vast majority of cVDPV cases and is a major challenge to achieving polio eradication. In countries and areas experiencing outbreaks of cVDPV2, type 2 monovalent OPV (mOPV2) or the next generation version of mOPV2, type 2 novel OPV (nOPV2), is being used to rapidly boost immunity in affected areas to help stem this growing threat.²³ 

Challenges

Although the polio vaccine is relatively inexpensive, challenges persist in delivering the vaccine to the most at-risk populations in endemic regions, as affected areas are often geographically remote and struggle with extreme poverty, conflict, and religious or other social barriers that hamper the ability of health care workers to reach all children who need to be vaccinated. Attacks on health care workers engaged in polio vaccination activities, most recently in Pakistan, have highlighted security concerns that threaten continued progress. To address some of these challenges, approaches have included:

• building political will among national and community leaders,
• mobilizing community support of sustained vaccination efforts,
• retaining public trust in the safety of the vaccine,
• ensuring vaccine supply,
• improving coordination among key players, and
• securing adequate financing.²⁴ 

Global Goals

With the Polio Eradication Strategy 2022–2026, key public and private stakeholders agreed to redouble efforts in the remaining endemic countries and to adopt a strategy for attaining the goal of eradicating polio (specifically, the remaining type WPV1) and validating the absence of cVDPV2 by 2026 that responds to current challenges while also preparing for a post-polio world.²⁵  Although eradication of WPV is still several years away, polio stakeholders have begun to plan for a post-polio world,²⁶  which will require efforts to transition but maintain polio assets (e.g., polio surveillance systems), document lessons learned, and complete the task of eradication by addressing VDPV.

Polio eradication is among the disease-specific goals of Immunization Agenda 2030, the global strategy for expanding access to and coverage of critical vaccines over the next decade.²⁷  Earlier, polio eradication was also a major milestone in the Global Vaccine Action Plan 2011-2020,²⁸  which outlined a vision for delivering universal access to immunization by 2020 as part of the “Decade of Vaccines” effort,²⁹  as first called for by Bill and Melinda Gates in 2010.³⁰  The Gates Foundation is also the largest contributor to the GPEI.³¹ 

U.S. Government Efforts

The U.S. has long been a leader in supporting global polio eradication, with the Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID) engaged in efforts to assist affected countries through bilateral activities as well as the GPEI. In recent years, growing international attention to progress made toward eradication has led the U.S. to emphasize the urgency of sustaining efforts until eradication is achieved and spurred U.S. involvement in new collaborations aimed at better reaching the areas and populations most affected by new cases. In 2009, President Obama launched a new joint effort with the Organization of Islamic Cooperation (an inter-governmental organization with 57 member-states spread over four continents) to eradicate polio globally, bringing high level support to efforts to counter the disease in endemic countries with large Muslim populations.³²  The resulting 2010 joint work plan aimed “to strengthen diplomatic advocacy, technical support and resource mobilization” on the part of the U.S. government and OIC member-states.³³ 

Protecting children from polio by ensuring they are fully immunized is part of the U.S. government maternal and child health strategy.³⁴ 

Organization

CDC and USAID are the major implementing agencies for U.S. global polio efforts, with CDC serving as the U.S. lead agency. The Department of State and the National Institutes of Health (NIH) also play important roles in the U.S. response.

CDC

CDC’s efforts focus on technical and financial assistance for efforts to interrupt WPV transmission. In addition to its polio surveillance expertise,³⁵  it offers field support through the deployment of public health professionals to polio-affected areas who support capacity building of surveillance and laboratory networks, immunization campaign planning and monitoring, social mobilization, and other activities.³⁶  In December 2011, CDC activated its Emergency Operations Center to “support the final push for polio eradication.”³⁷ 

Other U.S. Polio Efforts

USAID provides technical support to country partners in immunization campaign planning and implementation, social mobilization and communications efforts, and strengthening surveillance and monitoring systems.³⁸  The agency’s early polio efforts focused on Latin America in the late 1980s and early 1990s, until the disease was eliminated in the region.³⁹  Since 1996 it has supported and worked with the Global Polio Eradication Initiative.⁴⁰  The Department of State supports U.S. efforts through diplomatic initiatives to engage political and community leaders in affected areas.⁴¹  NIH and CDC efforts also focus on encouraging research into and adoption of new polio vaccines.

Multilateral Engagement

Additionally, the U.S. works closely with international institutions and other partners, including the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and Rotary International. It is also the second largest donor to the Global Polio Eradication Initiative, having contributed almost $4.3 billion since its launch in 1988.⁴² 

Funding

Total U.S. funding for polio has risen from $134 million in FY 2009 to $253 million in FY 2022 (see figure).⁴³ 

Most U.S. funding for polio is provided through CDC’s global immunization program (about 70%). Additional polio funding is provided under the maternal and child health (MCH) program at USAID. See the KFF fact sheet on U.S. MCH efforts.

Key Issues for the U.S.

Increased attention to polio, when coupled with global partnerships and the availability of effective interventions, offer a unique opportunity to eradicate an infectious disease affecting humans for only the second time in history. However, with continued insecurity and difficulty accessing hard-to-reach areas in some of the remaining endemic areas and other ongoing challenges, concerns about how to not only sustain gains made but also eliminate the final reservoirs of the poliovirus exist. For one, in recent years, access to certain areas in Afghanistan has been hampered by security issues, but with Taliban support, nationwide polio vaccination efforts in Afghanistan resumed in November 2021 for the first time in more than three years, allowing polio campaigns to once again reach children in all areas and pushing polio to its lowest levels ever there.⁴⁴  Additionally, there was concern that the coronavirus pandemic would significantly affect these efforts, with global polio immunization campaigns paused for several months in the spring of 2020 and polio assets often made available to support the COVID-19 response while maintaining “critical polio functions.”⁴⁵  Though efforts to stem transmission were stymied by the pause,⁴⁶  polio campaigns resumed in July 2020,⁴⁷  and polio efforts now may be benefitting from heightened community awareness of the benefits of vaccinations due to the COVID-19 vaccination effort.⁴⁸  The spread of VDPV is another major issue on the path to eradication that will be important to monitor and address, including in the United States⁴⁹  and other countries and areas where cVDPV has been found.

Going forward, U.S. support for ongoing global polio efforts and their role in contributing to not only polio eradication efforts but also global health security and emergency response efforts will remain an area to watch as broader discussions about strengthening pandemic preparedness and response continue to evolve.

To achieve the vision of eradicating polio, securing adequate funding for the final stretch of the Global Polio Eradication Initiative will be important.⁵⁰  Additionally, addressing the significant challenge of tackling VDPV will require sustained support and resources even after eradication of WPV is achieved and particularly as efforts to secure a post-polio world get further underway.

1. GPEI, “History of Polio,” webpage, http://polioeradication.org/polio-today/history-of-polio/. ↩︎
2. In 2021, most of these cases occurred in endemic countries (4 in Afghanistan and 1 in Pakistan), with 1 importation case in Malawi. ↩︎
3. In 2021, 647 of these cases occurred in non-endemic countries, while 51 occurred in endemic countries (43 in Afghanistan and 8 in Pakistan). ↩︎
4. Certification of polio eradication occurs after a sustained period of time with no transmission of WPV. Detailed criteria are described at: GPEI, “Certification,” webpage, http://polioeradication.org/polio-today/preparing-for-a-polio-free-world/certification/. ↩︎
5. In 1980, the World Health Assembly (WHA) accepted scientific certification that smallpox had been eradicated worldwide. WHO, The Global Eradication of Smallpox, 1980. Guinea-worm disease (a neglected tropical disease also known as dracunculiasis) could become the second disease eradicated; cases dropped from 3.5 million annually in the mid-1980s to 27 in 2020. WHO, “Dracunculiasis (guinea-worm disease),” fact sheet, Jan. 2022. ↩︎
6. GPEI Independent Monitoring Board, “Letter to Margaret Chan dated Jan. 18, 2013,” http://polioeradication.org/wp-content/uploads/2016/07/Letter_January2013_EN.pdf. ↩︎
7. GPEI, “History of Polio,” webpage, http://polioeradication.org/polio-today/history-of-polio/. ↩︎
8. 41st WHA, “Global eradication of poliomyelitis by the year 2000,” WHA 41.28, 1988; GPEI, “Who We Are,” webpage, http://polioeradication.org/who-we-are/. ↩︎
9. Includes contributions and pledges through 2021. GPEI, “Contributions and Pledges to the Global Polio Eradication Initiative, 1985-2021,” as of Dec. 31, 2021, http://polioeradication.org/financing/donors/historical-contributions/. ↩︎
10. 65th WHA, “Poliomyelitis: intensification of the global eradication initiative,” WHA 65.5, 2012. ↩︎
11. WHO Executive Board, Poliomyelitis, Report by the Secretariat, EB136/21, Jan. 16, 2015; GPEI, “Public Health Emergency Status,” webpage, http://polioeradication.org/polio-today/polio-now/public-health-emergency-status/. ↩︎
12. These years represent the dates of regional certification of eradication. UNICEF, “The Story of the End of Polio,” www.unicef.org/immunization/files/The_Story_of_the_End_of_Polio.pdf; GPEI, “WHO South-East Asia Region Declared Polio-Free,” March 27, 2014, http://polioeradication.org/news-post/who-south-east-asia-region-declared-polio-free/; WHO, “Global polio eradication initiative applauds WHO African region for wild polio-free certification,” Aug. 25, 2020, https://www.who.int/news/item/25-08-2020-global-polio-eradication-initiative-applauds-who-african-region-for-wild-polio-free-certification. ↩︎
13. Sustained poliovirus transmission for over 12 months following importation is classified as re-established transmission. ↩︎
14. GPEI, “Where We Work,” webpage, http://polioeradication.org/where-we-work/. ↩︎
15. WPV 2 was eliminated in 1999 and declared eradicated in 2015, while WPV 3 was eliminated in 2012 and declared eradicated in 2019. WHO, “Poliomyelitis,” fact sheet no. 114, July 2019; Global Certification Commission, “Declaration of WPV2 Eradication,” Sept. 20, 2015; Global Certification Commission, “Declaration of WPV3 Eradication,” Oct. 17, 2019; CDC, “Global Certification of Eradication of Indigenous Wild Poliovirus Type 3,” field stories, https://www.cdc.gov/globalhealth/immunization/stories/global-certification-of-eradication-of-indigenous-wild-poliovirus-type-3.html. ↩︎
16. Most people infected with polio will have no symptoms, and those that do will usually experience minor symptoms that often resolve completely. ↩︎
17. WHO, “Poliomyelitis,” fact sheet no. 114, April 2013 and July 2022. ↩︎
18. Surveillance efforts include monitoring for cases of acute flaccid paralysis (AFP), an early sign of possible polio. ↩︎
19. According to GPEI, “Priority areas include those where polio cases have been found over the previous three years and where access to health care is difficult. Other criteria include high population density, high population mobility, poor sanitation, and low routine immunization coverage.” GPEI, “Targeted Mop-up Campaigns,” webpage, http://polioeradication.org/who-we-are/strategic-plan-2013-2018/targeted-mop-up-campaigns/. ↩︎
20. Herd immunity is the resistance to an infectious agent of an entire group or community (and, in particular, protection of susceptible persons) as a result of a substantial proportion of the population being immune to the agent. See CDC, “Glossary of Epidemiology Terms,” webpage, https://www.cdc.gov/csels/dsepd/ss1978/glossary.html. ↩︎
21. Polio Oversight Board, “Polio Eradication in Reach, with Renewed Commitment,” statement, Sept. 25, 2015. Also see GPEI, ”Vaccine-Derived Polioviruses,” webpage, http://polioeradication.org/polio-today/polio-prevention/the-virus/vaccine-derived-polio-viruses/; WHO, “Poliomyelitis: Vaccine derived polio?,” Online Q&A, April 2017, https://www.who.int/news-room/questions-and-answers/item/poliomyelitis-vaccine-derived-polio; GPEI, “Vaccine-Derived Poliovirus,” fact sheet, Nov. 2019, http://polioeradication.org/wp-content/uploads/2016/07/GPEI-cVDPV-factsheet_March-2017.pdf. ↩︎
22. WHO/GPEI: “Planning for IPV Introduction: FAQs,” March 2014; “Preparing for the withdrawal of all OPVs,” OPV Switch Briefing Note, Feb. 2015. Olen Kew and Mark Pallansch, “Breaking the Last Chains of Poliovirus Transmission: Progress and Challenges in Global Polio Eradication,” July 2018, Annual Review of Virology 2018: 5:7.1-7.25. ↩︎
23. GPEI, GPEI Strategy for the Response to cVDPV2 2020-2021, fact sheet, March 2021; GPEI, “cVDPV2 Outbreaks and the Type 2 Novel Oral Polio Vaccine (nOPV2),” Jan. 2022, https://polioeradication.org/wp-content/uploads/2022/01/GPEI_cVDPV2-nOPV2_Factsheet_13-Jan-2022-EN.pdf. ↩︎
24. The GPEI Independent Monitoring Board monitors progress toward GPEI milestones, examines key challenges, and makes recommendations accordingly; see http://polioeradication.org/who-we-are/governance-and-structure/independent-monitoring-board/. ↩︎
25. GPEI, Polio Eradication Strategy 2022–2026, 2021. ↩︎
26. GPEI, “Transition Planning,” webpage, https://polioeradication.org/polio-today/preparing-for-a-polio-free-world/transition-planning/; GPEI, Polio Post-Certification Strategy: A risk mitigation strategy for a polio-free world, 2018, http://polioeradication.org/polio-today/preparing-for-a-polio-free-world/transition-planning/polio-post-certification-strategy/; WHO, Polio transition planning, Report by the Director-General, EB142/11, Jan 12, 2018, http://apps.who.int/gb/ebwha/pdf_files/EB142/B142_11-en.pdf; WHO, Strategic Action Plan on Polio Transition, Report by the Director-General, May 2018, https://www.who.int/publications/i/item/A71-9; WHO, Polio Transition Programme, webpage, https://www.who.int/teams/polio-transition-programme. ↩︎
27. WHO, Immunization Agenda 2030: A Global Strategy to Leave No One Behind, 2020, https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030. ↩︎
28. WHO, Global Vaccine Action Plan 2011-2020, http://www.who.int/immunization/global_vaccine_action_plan/GVAP_doc_2011_2020/en/. ↩︎
29. The secretariat for the Decade of Vaccines Collaboration dissolved in 2012 after the Global Vaccine Action Plan was developed, with the aim that partners’ efforts in support of the plan and global immunization efforts would continue. Decade of Vaccines Collaboration, website, www.dovcollaboration.org/. ↩︎
30. The Decade of Vaccines Collaboration grew out of Bill and Melinda Gates’ initial call for the next ten years to focus on helping “to research, develop, and deliver vaccines for the world’s poorest countries.” See Gates Foundation, media release, 2010, www.gatesfoundation.org/Media-Center/Press-Releases/2010/01/Bill-and-Melinda-Gates-Pledge-$10-Billion-in-Call-for-Decade-of-Vaccines and www.gatesfoundation.org/Media-Center/Press-Releases/2010/12/Global-Health-Leaders-Launch-Decade-of-Vaccines-Collaboration. ↩︎
31. GPEI, “Contributions and Pledges to the Global Polio Eradication Initiative, 1985-2021,” as of Dec. 31, 2021, http://polioeradication.org/financing/donors/historical-contributions/. ↩︎
32. Formerly known as the Organization of the Islamic Conference. Obama Administration/White House, “Remarks by the President on a New Beginning,” June 4, 2009, https://obamawhitehouse.archives.gov/the-press-office/remarks-president-cairo-university-6-04-09. ↩︎
33. Obama Administration/State Department, “United States Support for Polio Eradication,” fact sheet, Oct. 7, 2010, https://2009-2017.state.gov/e/oes/rls/fs/2010/149227.htm. ↩︎
34. USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action, June 2014; Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008; Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009. ↩︎
35. CDC provides virological surveillance expertise (genetic fingerprinting) to investigate polio cases, identify the strain of poliovirus involved, and pinpoint genetic and transmission linkages. KFF communication with CDC, May 2013. ↩︎
36. CDC, “Polio,” webpage, www.cdc.gov/polio/. ↩︎
37. CDC, CDC Global Health Strategy, 2012-2015, 2012. ↩︎
38. USAID, Global Health and Child Survival: Progress Report to Congress, 2010-2011, 2012; USAID, “Support to Polio Eradication Activities,” fact sheet, Aug. 3, 2015, and webpage updates May 7, 2019 and Oct. 6, 2021, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/technical-areas/immunization/polio. ↩︎
39. The last case in Latin America occurred in 1991, and the region was certified polio-free in 1994. ↩︎
40. USAID, Polio Eradication Initiative Mission Information Kit, 1999. ↩︎
41. Obama Administration/State Department, “United States Support for Polio Eradication,” fact sheet, Oct. 7, 2010, https://2009-2017.state.gov/e/oes/rls/fs/2010/149227.htm. ↩︎
42. Includes funding through 2022. GPEI, “Contributions and Pledges to the Global Polio Eradication Initiative, 1985-2021,” as of December 31, 2021, http://polioeradication.org/financing/donors/historical-contributions/; KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. ↩︎
43. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. ↩︎
44. GPEI, “Afghanistan makes progress in polio eradication but challenges remain,” Aug. 15, 2022, https://polioeradication.org/news-post/afghanistan-makes-progress-in-polio-eradication-but-challenges-remain/ ; Reuters, “WHO, UNICEF launch Afghan polio vaccine campaign with Taliban backing,” Nov. 8, 2021, https://www.reuters.com/world/asia-pacific/who-unicef-launch-afghan-polio-vaccine-campaign-with-taliban-backing-2021-11-08/; Haroon Janjua, “Afghanistan to restart polio vaccination programme with Taliban support,” Oct. 19, 2021, https://www.theguardian.com/global-development/2021/oct/19/afghanistan-to-restart-polio-vaccination-programme-with-taliban-support. ↩︎
45. GPEI, “Call to Action to Support Covid-19 Response,” Polio Oversight Board Statement, April 2, 2020, http://polioeradication.org/wp-content/uploads/2020/04/POB-COVID-19-Statement-20200402.pdf. ↩︎
46. GPEI, GPEI Strategy for the Response to cVDPV2 2020-2021, fact sheet, March 2021, https://polioeradication.org/wp-content/uploads/2021/03/GPEI-cVDPV2-nOPV2-Factsheet-20210312-EN.pdf. ↩︎
47. GPEI, Latest on COVID-19: GPEI’s Situation Report & Donor Update, Aug. 4, 2020, https://polioeradication.org/wp-content/uploads/2020/08/GPEI-Newsletter-Week32-2020.pdf. ↩︎
48. Mohammad Ali, et al., “COVID-19 vaccination gives hope to eradicate polio,” Nature Medicine, Vol. 27, pp. 1660–1661, correspondence, Oct. 4, 2021, https://www.nature.com/articles/s41591-021-01518-z. ↩︎
49. GPEI, “Updated statement on report of polio detection in United States,” July 29, 2022, https://polioeradication.org/news-post/report-of-polio-detection-in-united-states/. ↩︎
50. GPEI, “Financial Resource Requirements,” webpage, http://polioeradication.org/financing/financial-needs/financial-resource-requirements-frr/; GPEI, Polio Investment Case, 2022-2026, 2022, https://polioeradication.org/wp-content/uploads/2022/04/GPEI-Investment-Case-2022-2026-Web-EN.pdf. ↩︎

On August 31, the Centers for Medicare and Medicaid released a proposed rule designed to make it easier for eligible people to obtain and maintain coverage in Medicaid and the Children’s Health Insurance Program (CHIP). Together, Medicaid and CHIP provide coverage to 89 million low-income people. The Affordable Care Act (ACA) made significant changes to help simplify, streamline, and coordinate eligibility and enrollment across health programs, especially for children and adults, but complexities remain, and some eligible people are not enrolled or churn on and off the program. While there are broad eligibility and enrollment rules, states administer the Medicaid program and there is considerable variation in eligibility, enrollment, and renewal policies. The proposed rule would create more uniform processes across states and are in line with the Biden Administration’s focus on strengthening coverage and access. While Medicaid eligibility is complex and the proposed rule contains many provisions, this policy watch highlights some of the most notable changes.

1. The proposed rule enhances timeliness requirements for state eligibility determinations and creates new requirements for states when they receive returned mail.

Existing rules specify that states are required to determine eligibility for Medicaid within 90 days for those applying on the basis of disability and 45 days for other applicants, but timeframes are not provided for when applicants need to provide additional information at renewal and for changes in circumstances. The proposed rule creates uniform requirements to help ensure applicants have sufficient time to submit required documentation to states at application, renewal and when changes in circumstances are reported. The proposed rule also specifies that states must check available data sources, conduct outreach using different modalities, and try to obtain forwarding address information before moving to terminate enrollees from coverage due to returned mail.

Data show that 1 in 10 Medicaid enrollees may disenroll and then re-enroll in Medicaid within one year (churn). Data also suggest that states implementing periodic eligibility checks between renewals may have contributed to Medicaid enrollment declines prior to the pandemic. Eligible individuals are at risk for losing coverage if they do not receive or understand forms requesting information to verify eligibility or do not respond to states’ requests within required timeframes. While many states have policies in place to conduct follow-up on returned mail, some states may disenroll individuals if mail is returned.

2. The proposed rule simplifies enrollment and renewal policies for people who are age 65 or older or have disabilities, many of whom are also enrolled in Medicare.

The ACA simplified eligibility processes for children and adults under age 65 who are not eligible on account of a disability. Eligibility for those populations depends on applicants’ Modified Adjusted Gross Income (MAGI) on their tax returns. The ACA established renewal requirements, such as using pre-populated renewal forms and conducting renewals on an annual basis. (A required renewal process on an annual basis is not the same as 12-month continuous eligibility, where enrollment is guaranteed for a year even if there are changes in income that have to be reported.) The proposed rule would apply similar simplified processes for people who are eligible because of a disability or being age 65 or older (referred to as “non-MAGI” populations because eligibility is not determined using MAGI).  A recent survey shows that all but one state (West Virginia) conduct annual renewals for non-MAGI populations, but 15 do not use pre-populated renewal forms.

The proposed rule would also make significant changes to the eligibility determination process for two specific groups of beneficiaries: those who are considered “medically needy” and those who are eligible for the Medicare Savings Programs (MSP), which provide coverage of Medicare premiums and in some cases, cost sharing, through the Medicaid program.

• In the 34 states that offer a Medically Needy or spend-down pathway, people who are considered “medically needy” must show that they meet Medicaid income eligibility requirements after deducting health care expenses. Individuals living in institutions are currently allowed to project their future spending for the purposes of determining eligibility. The proposed rule would extend the same flexibility to some enrollees living in home and community settings.
• People who are eligible for MSP are also eligible for Medicare’s Low-Income Subsidy (LIS) for prescription drug coverage and the proposed rule would leverage LIS eligibility and enrollment data to streamline the MSP enrollment process. Integrating those systems could increase enrollment as data show that over 1.1 million people were enrolled in LIS and eligible for—but not enrolled in—MSP. Changes include ensuring that applications for LIS also are treated as applications for MSP, encouraging states to use the definitions of income and wealth that are used for determining LIS eligibility (which tend to be higher than the MSP income and wealth limits), and auto-enrolling LIS applicants who are receiving Supplemental Security Income.

3. The proposed rule also prohibits some policies that may be enrollment barriers for children in CHIP.

The proposed rule would eliminate waiting periods (or periods of uninsurance), coverage lockouts for failure to pay premiums, and annual or lifetime caps on benefits for children enrolled in separate CHIP (S-CHIP) programs. These policies are not permitted in Medicaid or other insurance affordability programs. Prior to the start of the pandemic, 13 states required waiting periods in S-CHIP of one month to 90 days, but two states have since eliminated their waiting periods. Additionally, prior to the pandemic, 14 states imposed a lockout period, usually 90 days, for failure to pay premiums. The proposed rule would also streamline processes to facilitate transitions between Medicaid and CHIP by requiring Medicaid and S-CHIP to accept eligibility determinations made by the other program, to develop procedures for each program to accept electronic transfers of information, and to provide combined notices for transitions between Medicaid and S-CHIP.

4. When fully implemented, the proposed rule is expected to increase coverage (and costs tied to new coverage) but reduce administrative costs and burden.

The Centers for Medicare & Medicaid Services (CMS) estimates that the rule would increase the number of person years of enrollment (a measure that calculates the number of new months of enrollment divided by 12) by nearly 3-million-person years after it is fully implemented in 2027 (Figure 1). The biggest source of new enrollment (1.5 million new person years) is due to changes made to eligibility processes for non-MAGI enrollees. Another 1.3 million new enrollment years come from changes relating to timeliness and returned mail policies that affect all Medicaid enrollees, and the final 0.1 million come from changes to the CHIP program.

The proposed rule estimates increased costs tied to Medicaid and CHIP enrollment gains of $23 billion in 2027 ($14.1 billion in federal funds and $9.1 in state funds), two-thirds of which results from changes affecting all Medicaid enrollees ($15.3 billion), Changes to non-MAGI rules account for $7.4 billion and the remaining $0.4 billion stems from changes to the CHIP program. In that year, CMS also estimates $2.6 billion in new Medicare spending, $4.0 billion in savings on subsidies provided through ACA marketplace coverage, and $1.2 billion in savings from lower administrative costs and improvements to program integrity. The estimated change in federal spending in 2027 would be $12.8 billion.

Estimates of increased coverage and costs are highly uncertain largely because it is hard to predict how states and people will respond to the new policies. It is also difficult to estimate how many people are eligible for, but not enrolled, in Medicaid and CHIP currently, particularly among people eligible for Medicaid on the basis of disability or being age 65 or older.

5. Looking ahead, CMS is seeking comments about how the proposed changes would intersect with the unwinding of the Public Health Emergency (PHE).

As CMS finalizes provisions in the rule sometime next year, implementation of the rule could coincide with the unwinding of the PHE. The Medicaid continuous enrollment requirement, which has been in place during the PHE, prevents states from disenrolling people from Medicaid; however, once the PHE ends, states will need to conduct redeterminations and renewals for all enrollees for the first time in over two years. CMS acknowledges that imposing these new requirements on states during the unwinding period following the end of the PHE could be challenging, even if the long-term effects are to make it easier for eligible individuals to enroll and retain coverage. In addition, recognizing states will need to make systems changes, and in some cases, legislative changes to comply with the requirements, CMS indicates it is considering an effective date 30 days following publication of the final rule while providing states with 12 months to come into full compliance. The agency seeks comment on the reasonableness of this timeframe.

Nearly 1 in 5 Parents of Children Under 5 Say Their Child Has Gotten a Vaccine, up from 7% in July, Though Half Say They Will “Definitely Not” Get Their Child Vaccinated

Less than a month after the Food and Drug Administration authorized new COVID-19 booster shots that target both the omicron and original strains, public awareness is modest, a new KFF COVID-19 Vaccine Monitor survey finds.

Half the public says they’ve heard either “a lot” (17%) or “some” (33%) about the new boosters, while the other half says they’ve heard “a little” or “nothing at all.” Older adults (ages 65 and up), who tend to be at greater risk for serious COVID-19 complications, are most likely to know about the new booster.

The Centers for Disease Control and Prevention has recommended that all vaccinated adults and children ages 12 and up get the new bivalent vaccine, even if they received a previous booster. About half of vaccinated adults (49%) say that they know the new vaccine is recommended for people like them, two in five (40%) are not sure, and 11% say that it is not recommended.

Fielded just weeks after the new booster became available, the new survey shows that about a third (32%) of adults say that they’ve either gotten the new booster (5%) or intend to do so as soon as possible (27%). Among older adults (ages 65 and up), nearly half (45%) say they’ve already gotten the new booster (8%) or plan to get it as soon as possible (37%).

“America is not rushing out to get the new booster. Most are only dimly aware of it, which is not surprising in a country that seems to have mostly moved on,” KFF President and CEO Drew Altman said. “The exception may be older folks, who are at greater risk and early on are more interested in the new booster.”

Adult vaccination rates overall have been relatively steady over the past year. Nearly eight in ten (77%) now say they have gotten at least one dose of any COVID-19 vaccine, including about half who got at least one booster dose (47%), a quarter who have been fully vaccinated but have not gotten a booster (26%), and a few who are partially vaccinated (3%). In addition, 23% are unvaccinated, the vast majority of whom say they will “definitely not” get a shot (88% of the unvaccinated, or 21% of all adults).

Rising Share of Parents with Young Children Report Getting Them Vaccinated

The new survey finds about one in five (19%) parents with children ages 6 months through 4 years report getting their child a COVID-19 vaccine, up significantly since July (7%) soon after children in that age group became eligible.

At the same time, slightly more than half (53%) of parents of these young children say they will “definitely not” get their child a vaccine, also up from earlier this year.

Among other parents with children in this age range, 6% say they plan to vaccinate their children “right away,” 14% say they want to “wait and see” how it works for others, and 8% say they will get them vaccinated “only if required” for school or other activities.

The new survey also provides updated data on what parents of older children say about their vaccine intentions:

• Almost half (46%) of parents with children ages 5-11 now report their child has gotten vaccinated, up a bit since earlier in this year. More than a third of these parents say they will “definitely not” get their child vaccinated.
• About six in ten parents of teenagers, ages 12-17, say their child has been vaccinated (62%), while nearly a third (31%) say they will definitely not get their child vaccinated.

Designed and analyzed by public opinion researchers at KFF, the Vaccine Monitor survey was conducted from Sept 15-26, 2022, online and by telephone among a nationally representative sample of 1,534 U.S. adults, in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

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

September marks National Hispanic American Heritage Month during which the U.S. recognizes the achievements and contributions of Hispanic people. As the country celebrates these achievements, it is key to recognize that Hispanic people face many disparities in health and health care that limit their overall health and well-being. Hispanic people make up 19% of the total U.S. population and are the second largest racial or ethnic group in the U.S. They are also the second fastest growing group, increasing from 50.5 million to 62.1 million between 2010 and 2020. Hispanic people living in the U.S. have a diverse heritage, with origins from over twenty countries and Puerto Rico. The majority of Hispanic people in the U.S. were born in the country, however 33% are immigrants, including 20% who are noncitizens. Overall, the Hispanic population is relatively young, including 26% who are children ages 18 or younger.

Despite gains in health coverage since the implementation of the Affordable Care Act, nonelderly Hispanic people continue to have some of the highest uninsured rates (20%) across racial/ethnic groups, although risk of being uninsured varies by their family heritage, with particularly high rates among those with roots in Central America. These higher uninsured rates, underlying social and economic inequities, and linguistic barriers contribute to increased challenges in accessing health care. Moreover, Hispanic people faced growing fears about accessing health coverage and other assistance due to shifting immigration policy under the Trump Administration and have experienced disproportionate health, social, and economic impacts from the COVID-19 pandemic. They also face increasing health risks associated with climate change. As a large and growing share of the population, addressing health challenges faced by Hispanic people will be important for improving their health and well-being and supporting overall improved health and prosperity of the country.  

This fact sheet does not reflect recent changes that have been implemented by the Trump administration, including a foreign aid review and restructuring. For more information, see KFF’s Overview of President Trump’s Executive Actions on Global Health.

Key Facts

• Millions of pregnant women, new mothers, and children experience severe illness or death each year, largely from preventable or treatable causes. Almost all maternal and child deaths (99%) occur in less developed regions, with Africa being the hardest hit region. There have been some gains: attention to maternal and child health (MCH) has been growing over the past decade, and under-five and maternal mortality have fallen substantially since 1990.
• The U.S. government (U.S.) has been involved in supporting global MCH efforts for more than 50 years and is the largest donor government to MCH activities in the world, in addition to being the single largest donor to nutrition efforts in the world.
• In recent years, the U.S. has placed a higher priority on MCH and adopted “ending preventable child and maternal deaths” as one of its three main global health goals.
• Total U.S. funding for MCH and nutrition was $1.435 billion in FY 2022, up from $728 million in FY 2006. This includes the U.S. contributions to Gavi, the Vaccine Alliance, and the U.N. Children’s Fund (UNICEF) as well as support for polio activities.
• Despite past gains, there is growing evidence that the COVID-19 pandemic has had a detrimental impact on MCH in many countries, and mitigating and reversing this impact presents new challenges for the U.S. and the global community.

Global Situation

The health of mothers and children is interrelated and affected by multiple factors.¹  Millions of pregnant women, new mothers, and children experience severe illness or death each year, largely from preventable or treatable causes.²  Almost all maternal and child deaths (99%) occur in less developed countries, with Africa being the hardest hit region.³  Attention to maternal and child health (MCH) has been growing over the past decade, under-five and maternal mortality have fallen substantially since 1990, and improving MCH is seen as critical to fostering economic development.

Still, as efforts focus on achieving new global MCH goals such as ending preventable deaths among newborns and children under five and reducing global maternal mortality, significant challenges remain. Although effective interventions are available, lack of funding and limited access to services have hampered progress, particularly on maternal health. There is growing evidence that the COVID-19 pandemic has had detrimental effects on maternal and child health and nutrition – slowing or even reversing some progress made over the past decade – by disrupting essential services including routine immunization efforts and fueling malnutrition.

Impact

Each year, an estimated 5 million children under age five – primarily infants – die from largely preventable or treatable causes.⁴  In addition, approximately 295,000 women die during pregnancy and childbirth each year, and millions more experience severe adverse consequences.⁵  These challenges are especially prevalent in developing countries. Furthermore, sub-Saharan Africa is the hardest hit region in the world, followed by Southern Asia and South-Eastern Asia; altogether they account for approximately 90% of maternal and under-five deaths.⁶ 

Maternal Mortality

More than a quarter (27%) of all maternal deaths are due to severe bleeding, mostly after childbirth (postpartum hemorrhage). Sepsis (11%), unsafe abortion (8%), and hypertension (14%) are other major causes. Diseases that complicate pregnancy, including malaria, anemia, and HIV, account for about 28% of maternal deaths.⁷  Inadequate care during pregnancy and high fertility rates, often due to a lack of access to contraception and other family planning/reproductive health (FP/RH) services, increase the lifetime risk of maternal death.⁸  While the percentage of pregnant women receiving the recommended minimum number of four antenatal care visits has been on the rise, it is only 66% globally and lower still in sub-Saharan Africa and Southern Asia.⁹ 

Newborn and Under-Five Mortality

Complications due to premature births account for more than a third (35%) of newborn deaths, followed by delivery-related complications (24%), sepsis (15%), congenital abnormalities (11%), pneumonia (6%), tetanus (1%), diarrhea (1%), and other causes of death (7%).¹⁰  Low birth weight is a major risk factor and indirect cause of newborn death.¹¹ 

Newborn deaths account for most child deaths (47%), followed by pneumonia (12%), diarrhea (8%), injuries (6%), malaria (5%), measles (2%), HIV/AIDS (1%), and other causes of death (21%).¹²  Undernutrition significantly increases children’s vulnerability to these conditions, as does the lack of access to clean water and sanitation.¹³ 

Interventions¹⁴ 

Key interventions that reduce the risk of maternal mortality include skilled care at birth and emergency obstetric care. Newborn deaths may be substantially reduced through increased use of simple, low-cost interventions, such as breastfeeding, keeping newborns warm and dry, and treating severe newborn infections. When scaled-up, interventions such as immunizations, oral rehydration therapy (ORT), and insecticide-treated mosquito nets (ITNs) have contributed to significant reductions in child morbidity and mortality over the last two decades. Other effective child health interventions include improved access to and use of clean water, sanitation, and hygiene practices like handwashing; improved nutrition; and the treatment of neglected tropical diseases (NTDs). Strengthening health systems and increasing access to services, including through community-based clinics, are also important, and interventions have been found to be more effective when integrated within a comprehensive continuum of care.¹⁵ 

Global Goals

There are several key global goals for expanding access to and improving MCH services, including:

SDGs 2 & 3: Save Mothers and Children’s Lives and End All Forms of Malnutrition

Global MCH targets were adopted in 2015 as part of Sustainable Development Goals (SDGs) 2 and 3 and are to, by 2030:

• reduce the global MMR¹⁶  and end preventable deaths of newborns and under-five children¹⁷  (as targets under SDG 3, which is “ensure healthy lives and promote well-being for all at all ages”); and
• end all forms of malnutrition (as a target under SDG 2, which is “end hunger, achieve food security and improved nutrition, and promote sustainable agriculture”).¹⁸ 

Among the global efforts designed to support countries’ progress toward meeting these goals is the Every Woman, Every Child (EWEC) movement and the Scaling Up Nutrition (SUN) movement, which were both launched in 2010. The U.N.-led EWEC movement aims to operationalize the 2015 Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016-2030) by combining the efforts of partners who commit to advancing MCH and related efforts with the goal of ending preventable maternal, newborn, child, and adolescent deaths and stillbirths by 2030, among other goals.¹⁸  The SUN movement is an initiative that aims to bring together partner efforts to support households and women, in particular, and which recognizes that nutrition, maternal health, and child survival are closely linked.¹⁹ 

Global Nutrition for Growth Compact

The Global Nutrition for Growth Compact includes a goal of reducing stunting in children and nutrient deficiencies in women and children. Endorsed in 2013 by more than 40 developing country and donor governments, including the U.S., as well as other stakeholders, it committed them to, by 2020:²⁰ 

• ensuring that at least 500 million pregnant women and children under two are reached with effective nutrition interventions;
• reducing the number of children under five stunted by at least 20 million; and
• saving at least 1.7 million under-fives by preventing stunting and increasing breastfeeding and treatment of severe acute malnutrition.

The Tokyo Nutrition for Growth Summit held in December 2021 provided an opportunity for governments to review the status of progress, including the impact of the COVID-19 pandemic on efforts, and to make new commitments in support of reaching SDG 2 by 2030; the next Summit will be hosted by France in 2024.²¹ 

U.S. Government Efforts

The U.S. has been involved in global MCH efforts for more than 50 years. The first U.S. international efforts in the area of MCH began in the 1960s and focused on child survival research, including pioneering research on ORT conducted by the U.S. military, the U.S. Agency for International Development (USAID), and the National Institutes of Health (NIH). Early programs included fortifying international food aid with vitamin A (deficiency of which can cause blindness, compromise immune system function, and retard growth among young children) and efforts to control malaria. The U.S. increased support for its child health efforts in FY 1985 when it provided $85 million for child survival activities, nearly doubling funding for this purpose. USAID then developed its first maternal health project in 1989 and introduced a newborn survival strategy in 2001.²²  Funding has increased over time and in FY 2022 reached its highest level to date ($1.435 billion). The U.S. government has adopted a longer-term goal of ending preventable child and maternal deaths by 2035.

Organization

USAID serves as the lead U.S. implementing agency for MCH activities, and its efforts are complemented by those of the Centers for Disease Control and Prevention (CDC), NIH, and the Peace Corps. Collectively, U.S. activities reach over 40 countries.²³ 

USAID

USAID funds a range of MCH interventions (see Table 1²⁴ ), and its MCH efforts focus on 25 “priority countries”, most of which are  in Africa and Southern Asia.²⁵  With a strategic emphasis on reaching the most vulnerable populations and improving access to and quality of care and services for mothers and children across U.S. global health efforts, the agency’s near-term goal had been to save 15 million child lives and 600,000 women’s lives from 2012 through 2020 in priority countries; these countries account for approximately 70% of global maternal and child deaths While short of achieving this goal, USAID reports that its efforts over the past ten years have helped save the lives of more than 9.3 million children and 340,000 women.²⁶  Additionally, in 2014, USAID released, for the first time, a multisectoral nutrition strategy that focuses on improving linkages among its humanitarian, global health, and development efforts to better address both the direct and underlying causes of malnutrition and to build resilience and food security in vulnerable communities.²⁷ 

Other U.S. MCH Efforts

CDC operates immunization programs, provides scientific and technical assistance, and works to build capacity in a broad array of MCH (and related RH) areas. It also serves as a World Health Organization Collaborating Center on reproductive, maternal, perinatal, and child health.²⁸  NIH addresses MCH by carrying out basic science and implementation research, sometimes in cooperation with other countries.²⁹  The Peace Corps carries out MCH-related volunteer projects around the world.³⁰ 

Additionally, U.S. global FP/RH efforts are also critical to improving MCH (the internationally agreed upon definition of reproductive health includes both FP and MCH), although Congress directs funding to and USAID operates these programs separately.³¹  (See the KFF fact sheet on U.S. international FP/RH efforts.)

Other U.S. global health and related efforts addressing conditions that threaten the health of many pregnant women, new mothers, and children include the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative (PMI), USAID’s NTD Program, Feed the Future, and clean water efforts under the Water for the Poor and Water for the World Acts. (See the KFF fact sheets on U.S. PEPFAR efforts, U.S. global malaria efforts, and U.S. global NTD efforts.)

Multilateral Efforts

The U.S. government partners with several international institutions and supports global MCH funding mechanisms. Key among them are:

• Gavi, the Vaccine Alliance (a multilateral financing mechanism aiming to increase access to immunization in poor countries to which the U.S. is one of the largest donors; see the KFF fact sheet on the U.S. and Gavi);³² 
• the Global Financing Facility (GFF, a partnership to improve the health of women, children, and adolescents through innovative financing in which the U.S. is an investor);³³ 
• the Global Polio Eradication Initiative (GPEI, a public-private partnership aiming to advance efforts to eradicate polio to which the U.S. is the second largest donor; see the KFF fact sheet on U.S. global polio efforts);³⁴  and
• the United Nations Children’s Fund (UNICEF, a U.N. agency aiming to improve the lives of children, particularly the most disadvantaged children and adolescents, to which the U.S. is the largest donor;³⁵  UNICEF is one of the largest purchasers of vaccines worldwide).³⁶ 

Funding³⁷ 

Total U.S. funding for MCH and nutrition, which includes the U.S. contributions to Gavi and UNICEF as well as support for polio activities, has increased over time. It rose from $728 million in FY 2006 to $1.435 billion in FY 2022, its highest level to date (see figure).³⁸  MCH funding totaled $1.28 billion in FY 2022 and includes $848 million for bilateral efforts (of which $253 million was for polio activities) and $429 million for multilateral efforts ($290 million for Gavi and $139 million for UNICEF). Nutrition funding, all of which was for bilateral efforts, totaled $158 million in FY 2022. The current administration has proposed a similar level of MCH and nutrition funding for FY 2023.

Most U.S. funding for MCH and nutrition is provided through the Global Health Programs account at USAID, with additional funding provided through the Economic Support Fund account. MCH funding is also provided through the International Organizations & Programs account at the State Department for the U.S. contribution to UNICEF and through CDC’s global immunization programs.³⁹  (See the KFF fact sheets on the U.S. Global Health Budget: Maternal & Child Health and the U.S. Global Health Budget: Nutrition.)

Although not included as part of core MCH funding, in FY 2021 the U.S. also appropriated $4 billion in emergency COVID-19 funding to Gavi to support COVID-19 vaccine procurement and delivery through COVAX (see the KFF brief on COVAX and the U.S. for more information).

1. George Schmid, et al., “The Lancet’s neonatal survival series,” The Lancet, Vol. 365, Issue 9474, p. 1845, May 28, 2005. ↩︎
2. U.N. Interagency Group on Child Mortality Estimates (IGME), Levels and Trends in Child Mortality Report 2019, 2019; IGME, Levels and Trends in Child Mortality Report 2020, 2020; WHO, Trends in maternal mortality: 1990 to 2017, 2019. ↩︎
3. U.N. IGME, Levels and Trends in Child Mortality Report 2020, 2020; WHO, Trends in maternal mortality: 1990 to 2017, 2019. ↩︎
4. U.N. IGME, Levels and Trends in Child Mortality Report 2021, 2021; WHO, “Children: improving survival and well-being fact sheet,” Sept. 2020, webpage, https://www.who.int/news-room/fact-sheets/detail/children-reducing-mortality. ↩︎
5. WHO, Trends in maternal mortality: 2000 to 2017, 2019; WHO/UNICEF, Countdown to 2015 Report, 2012; WHO, “Maternal mortality fact sheet,” Sept. 2019, webpage, https://www.who.int/news-room/fact-sheets/detail/maternal-mortality. ↩︎
6. U.N. IGME, Levels and Trends in Child Mortality Report 2021, 2021; WHO, Trends in maternal mortality: 2000 to 2017, 2019. ↩︎
7. L. Say, et al., “Global causes of maternal death: a WHO systematic analysis,” The Lancet Global Health, Vol. 2, no. 6, pp. 323-333, June 2014. ↩︎
8. WHO and UNICEF, Countdown to 2015 Report, 2012. ↩︎
9. UNICEF, “Antenatal care,” webpage, July 2022, https://data.unicef.org/topic/maternal-health/antenatal-care/. ↩︎
10. U.N. IGME, Levels and Trends in Child Mortality Report 2019, 2019. ↩︎
11. Black, et al., for the Child Health Epidemiology Reference Group of WHO and UNICEF, “Global, Regional, and National Causes of Child Mortality in 2008: A Systematic Analysis,” The Lancet, Vol. 375, Issue 9730, pp. 1969–87, 2010. ↩︎
12. Does not sum to 100 due to rounding. UN IGME, Levels and Trends in Child Mortality Report 2019, 2019; UN IGME, Levels and Trends in Child Mortality Report 2020, 2020; UN IGME, Levels and Trends in Child Mortality Report 2021, 2021. ↩︎
13. Robert E. Black, et al., “Maternal and child nutrition: building momentum for impact,” The Lancet, Vol. 382, Issue 9890, pp. 372-375, Aug. 3, 2013; CRS, Child Survival and Maternal Health: U.S. Agency for International Development Programs, FY2001-FY2008, July 2008. Per the UN IGME, Levels and Trends in Child Mortality Report 2017, 2017, “nearly half of all deaths in children under age 5 are attributable to undernutrition.” ↩︎
14. USAID, Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008; UN, The Millennium Development Goals Report 2009, 2009; The Millennium Development Goals Report 2010, 2010; and The Millennium Development Goals Report 2011, 2011; USAID, Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009; UN IGME, Levels and Trends in Child Mortality Report 2013, 2013. ↩︎
15. Partnership for Maternal, Newborn & Child Health, Strategic Framework 2012-2015, November 2011. ↩︎
16. To less than 70 per 100,000 live births. ↩︎
17. For neonatal mortality, to at least as low as 12 per 1,000 live births, and for under-five mortality, to at least as low as 25 per 1,000 live births. ↩︎
18. U.N., Transforming our world: the 2030 Agenda for Sustainable Development, 2015. ↩︎
19. Its secretariat is located in the United Nations Office for Project Services. SUN, “Frequently Asked Questions,” webpage, https://scalingupnutrition.org/about-sun/frequently-asked-questions/; SUN, “The Vision and Principles of SUN,” webpage, http://scalingupnutrition.org/about-sun/the-vision-and-principles-of-sun/. ↩︎
20. The Global Nutrition for Growth Compact, June 2013, http://www.who.int/pmnch/media/events/2013/nutritionforgrowth/en/. Progress toward the compact’s goals is tracked by, among others, the Nutrition for Growth partnership, which is led by the governments of the United Kingdom, Brazil, and Japan governments, and involves philanthropic foundations and civil society organizations; see Nutrition for Growth website,  https://nutritionforgrowth.org/updates/. ↩︎
21. Tokyo Nutrition for Growth Summit, “More than US$27 billion committed to tackle global malnutrition and hunger crisis at the Tokyo Nutrition for Growth Summit,” press release, Dec. 8, 2021, https://nutritionforgrowth.org/tokyo-n4g-summit-2021-press-release/. ↩︎
22. USAID: MCH website, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health; Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008; Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009; USAID Reports to Congress, 1985, 1987, 1990. ↩︎
23. KFF analysis of data from the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. Additional countries may be reached through USAID regional programs and other efforts. ↩︎
24. USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID Maternal Health Vision for Action, June 2014; “USAID’s Investments Save the Lives of Women and Children,” 2019. ↩︎
25. According to USAID, Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014, priority countries are chosen based on need (as reflected by maternal and child mortality burden) and having: governments that have demonstrated a commitment to working with others to achieve accelerated reductions in maternal and under-five mortality; and opportunities to integrate/leverage other U.S. global health and development efforts as well as leverage USAID resources against those of the partner-country and other donors/organizations. Additional countries may be reached through other country and regional programs. USAID, “Maternal and Child Health Priority Countries,” webpage, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/priority-countries; USAID, “Maternal and Child Health,” webpage, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health. ↩︎
26. USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID Maternal Health Vision for Action, June 2014; “USAID Global Health Programs: FY 2016 President’s Budget Request, Ending Preventable Child and Maternal Deaths,” fact sheet, March 2015; “USAID Global Health Programs Ending Preventable Child and Maternal Deaths – FY 2017,” fact sheet, undated, USAID, Acting on the Call: Preventing Child & Maternal Deaths: A Focus on the Role of Nurses and Midwives, 2020; USAID, Acting on the Call: Preventing Child and Maternal Deaths: A Focus on Sustaining Lifesaving Health Services Amidst the COVID-19 Pandemic, Nov. 2021. ↩︎
27. USAID, USAID Multi-Sectoral Nutrition Strategy 2014-2025, 2014. USAID reports prioritizing nutrition efforts in 22 focus countries, which are mostly in Africa. 16 of these countries are also MCH priority countries. USAID, “Nutrition Countries,” webpage, https://www.usaid.gov/global-health/health-areas/nutrition/countries. ↩︎
28. CDC, “About DRH Global Reproductive Health,” website, www.cdc.gov/reproductivehealth/Global/index.htm; WHO Collaborating Centres Global Database, “WHO Collaborating Centre for Reproductive Health,” USA-374, webpage, https://apps.who.int/whocc/Detail.aspx?tBVp7HlRcT5vnFl/XfLrgw==. According to WHO, “WHO collaborating centres are institutions such as research institutes, parts of universities or academies, which are designated by the Director-General to carry out activities in support of the Organization’s programmes.” See WHO, “WHO Collaborating Centres,” webpage, https://www.who.int/about/partnerships/collaborating-centres, for more information. ↩︎
29. NIH/NICHD Office of Global Health website, https://www.nichd.nih.gov/about/org/od/ogh; NIH Office of Research on Women’s Health, “Global Health Research,” webpage, https://orwh.od.nih.gov/research/funded-research-and-programs/co-funded-research/global-health-research; NIH/FIC, “Maternal and child health news, resources and funding for global health researchers,” webpage, https://www.fic.nih.gov/ResearchTopics/Pages/maternal-child-health.aspx. ↩︎
30. Peace Corps, “What Volunteers Do: Health,” webpage, https://www.peacecorps.gov/volunteer/what-volunteers-do/#health. ↩︎
31. International Conference on Population and Development (ICPD), Programme of Action, Cairo, 1994. ↩︎
32. Gavi has provided over $21 billion for vaccination programs worldwide through June 30, 2021, not including funding for COVAX. Gavi, “Cash Receipts 30 June 2021,” https://www.gavi.org/news-resources/document-library/cash-receipts. ↩︎
33. The GFF was launched in 2015 as “a multi-stakeholder global partnership housed at the World Bank that is committed to ensuring all women, children and adolescents can survive and thrive” and that “supports 36 low and lower-middle income countries with catalytic financing and technical assistance to develop and implement prioritized national health plans to scale up access to affordable, quality care for women, children and adolescents” (see https://www.globalfinancingfacility.org/introduction). The U.S. is as a member of the Investors Group that oversees the partnership’s overall activities (see https://www.globalfinancingfacility.org/investors-group). See also USAID, “USAID’s Partnership with the Global Financing Facility,” fact sheet, Aug. 2019, https://www.usaid.gov/documents/1864/usaid%E2%80%99s-partnership-global-financing-facility. ↩︎
34. GPEI has invested about $19 billion in efforts to eradicate polio globally. KFF analysis of funding based on data in GPEI, “Contributions and Pledges to the GPEI, 1985-2022,” as of 31 Dec. 2021, http://polioeradication.org/financing/donors/historical-contributions/ and data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. ↩︎
35. In 2021. UNICEF, “Funding to UNICEF,” webpage, https://www.unicef.org/partnerships/funding. ↩︎
36. UNICEF, “About UNICEF,” webpage, https://www.unicef.org/about-unicef; UNICEF, UNICEF Annual Report 2021, May 2022, https://www.unicef.org/reports/unicef-annual-report-2021; UNICEF, “Funding to UNICEF,” webpage, https://www.unicef.org/partnerships/funding; UNICEF, “Immunization,” webpage, https://www.unicef.org/immunization. ↩︎
37. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. ↩︎
38. Prior to FY 2009, nutrition funding was included as part of maternal and child health. ↩︎
39. Represents specified funding for international MCH and nutrition programs in the President’s budget request, ForeignAssistance.gov, and Congressional appropriations bills. Additional support for international MCH and nutrition programs is provided through research activities at NIH. ↩︎

Section 1115 demonstration waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute, as long as the federal Centers for Medicare and Medicaid Services (CMS) determines that such proposals are “likely to assist in promoting the objectives of the [Medicaid] program.” While Section 1115 waivers have been used over time, recent activity from the Trump Administration and into the Biden Administration has tested how these waivers can be used to advance administrative priorities and has also tested the balance between states’ flexibility and discretion by the federal government. The Trump Administration’s Section 1115 waiver policy emphasized work requirements and other eligibility restrictions, payment for institutional behavioral health services, and capped financing. The Biden Administration has signaled a shift in policy to emphasize waivers that expand, rather than restrict, Medicaid coverage and access to care. The Biden Administration has withdrawn work requirements and started to phase out premium requirements, and has instead encouraged states to propose waivers that expand coverage, reduce health disparities, and/or advance “whole-person care” (including addressing health-related social needs). This policy watch describes the current landscape of Section 1115 waivers and highlights key issues to watch: the outcome of litigation related to Georgia’s waiver, as well as the Biden Administration’s decisions on pending requests from Tennessee and other states.

As of September 20, 47 states have a total of 65 approved Section 1115 Medicaid waivers, while 28 states have a total of 32 pending waivers (Figure 1). Pending waivers include new waiver requests and pending extensions or amendments to existing approved waivers. Key themes in current approved and pending waivers include targeted eligibility expansions, benefit expansions (particularly in the area of behavioral health, such as coverage of services provided in institutions for mental disease (IMDs)), and provisions related to social determinants of health (SDOH). More detail on these areas can be found on the updated KFF waiver tracker.

Key Issues to Watch

What will happen with Georgia’s Pathways waiver? The Trump Administration aimed to reshape the Medicaid program by newly approving Section 1115 waivers that imposed work and reporting requirements as a condition of Medicaid eligibility; however, courts struck down many of these requirements and the Biden Administration withdrew these provisions in all states that had approvals. One state affected by these administrative activities was Georgia: in December 2021, CMS rescinded work requirement and premium authorities that the Trump Administration had approved as part of a limited coverage expansion (at the state’s regular match rate for federal funding) in Georgia’s waiver—an action that the state subsequently challenged in court. In August 2022, a Federal District Court judge issued a decision in favor of the state, vacating CMS’s rescission of the work requirement and premium provisions and thus reinstating these provisions. Although CMS generally reserves the right to withdraw waiver authorities at any time, the judge found that its rescission of Georgia’s waiver provisions was arbitrary and capricious due to agency errors, including that it failed to weigh that the waiver would have increased Medicaid coverage. CMS has not yet indicated whether it will appeal this decision.

How will the Biden Administration respond to an amendment to Tennessee’s TennCare III waiver?  In January 2021, CMS under the Trump Administration approved a waiver request from Tennessee that set an aggregate cap on federal spending and provided an opportunity for the state to keep a portion of any federal savings. Other controversial aspects of the approval included a closed prescription drug formulary and a 10-year approval period. In June 2022, CMS under the Biden Administration sent a letter to Tennessee asking the state to submit an amendment that would remove the aggregate cap and closed formulary provisions. Tennessee subsequently submitted an amendment that removed these provisions, instead transitioning to a per-capita budget neutrality cap that would allow the state to access the federal share of any savings if expenditures are lower than the cap to invest in Designated State Investment Programs (DSIPs). The amendment leaves the 10-year approval period (through 2030) in place. The waiver is open for federal comment through October 6, but it is unclear how the Biden Administration will respond to the revised financing request.

What provisions will be approved in several key waivers that expire at the end of September? Several states have Section 1115 demonstrations set to expire on September 30. Key provisions to watch in extension proposals from these states would: address enrollees’ SDOH and health equity; expand pre-release services available to incarcerated populations; and provide continuous eligibility for adults and children (Table 1). CMS has indicated an openness to approving some of these provisions, which may align with its strategic priorities under the Biden Administration. For example, in a June 2022 letter to Massachusetts, CMS wrote that it “strongly supports the goals set forth in the state’s extension proposal” and that “CMS and Massachusetts are jointly committed to finalizing the state’s demonstration extension by September 30, 2022, including approval of…authorities necessary to achieve our shared goals.”

The outcome of waiver proposals and litigation could have implications for other states. The court decision in favor of Georgia calls Section 1115 policy and process into question by limiting CMS’s authority to determine whether already-approved waivers advance Medicaid program objectives. Especially if CMS appeals the decision, the outcome of the case could have implications for other states that may similarly seek limited coverage expansions conditioned on other provisions (like work requirements and/or premiums). Upcoming CMS decisions on Tennessee’s amendment and waivers expiring at the end of September may indicate how the Biden Administration will respond to financing proposals and the extent to which the administration will allow states to use waivers for coverage for incarcerated individuals, to address social determinants of health, and for continuous coverage. In addition to Arizona, Massachusetts, and Oregon, other states are requesting similar provisions in waivers pending or in development at the state level. For example, 10 states in total have pending waivers to provide pre-release coverage to certain incarcerated individuals (Arizona, California, Kentucky, Massachusetts, Montana, New Jersey, Utah, Vermont, Washington, and West Virginia) and five states have pending waivers to provide continuous eligibility for certain populations (Kansas, Massachusetts, New Jersey, Oregon, and Washington). Similar to Oregon, Washington and New Mexico (whose waiver is currently undergoing state-level public comment) are both pursuing continuous enrollment for children through age six. Potential approval of these demonstrations could allow the Biden Administration to promote its strategic Medicaid priorities, which include expanded access to coverage.