Asian, Native Hawaiian, and Other Pacific Islander (NHOPI) people are a diverse and growing population in the U.S. (Figure 1). Asian people are the fastest-growing racial or ethnic group in the United States, almost doubling from 10.5 million to almost 20 million between 2000 and 2020. In addition, there are nearly 700,000 people in the country who identify as NHOPI. In this data note, we use 2021 American Community Survey (ACS) data to examine how demographic characteristics as well as measures of health coverage and other social and economic factors that drive health and health care vary for Asian and NHOPI people overall and by subgroups. We include data for smaller subgroups wherever available. Instances in which the unweighted sample size for a subgroup is less than 50 – which are smaller than what we would typically include in analysis like this — are noted in the figures, and confidence intervals for those measures are included in the Appendix. Although these small sample sizes may impact the reliability, validity, and reproducibility of data, they are important to include because they point to potential underlying disparities that are hidden without disaggregated data, further exacerbating health inequities.

Examining experiences among Asian and NHOPI people is important since broad data for Asian people often mask underlying disparities among subgroups of the population and disaggregated data are often not available or reported for NHOPI people. Understanding the experiences of Asian and NHOPI people is particularly important at this time given growing concerns about mental health and well-being amid a significant uptick in anti-Asian hate incidents since the pandemic, an increased focus on advancing health equity and addressing racism, and ongoing efforts to improve data collection and reporting, particularly for smaller population groups and subgroups of the broader racial and ethnic categories.

Demographics

The majority of Asian and NHOPI people in the U.S. are citizens, adults, and many are parents or living in multigenerational households (Figure 2). Asian and NHOPI people included larger shares of noncitizens relative to White people (25% and 14% vs. 1%). One in five Asian (20%) and 19% White people were children, while more than one in four (26%) NHOPI people were children. Larger shares of Asian people lived in households comprised of parents with children or multigenerational households as compared to White people (42% vs. 33%).

Citizenship and household status varied among Asian and NHOPI subgroups: For example, the share of Asian people who are noncitizens ranged from 5% among Hmong people to 55% among Mongolian people. Among NHOPI people, Native Hawaiian and Chamorro people were significantly less likely than NHOPI people overall to be noncitizens (at less than 1%). In contrast, Marshallese people were more likely to be noncitizens (54%). This variation reflects differences in birth citizenship rights across locations to which NHOPI people trace their origins. Specifically, people born in Hawaii and Guam (Chamorro people) are U.S. citizens by birth, while other Pacific Islander people, including those born in in the Marshall Islands, which is part of the Compact of Free Association (COFA) with the U.S are not conferred U.S. citizenship at birth. The share of these groups who are children also ranged widely, from 9% of Japanese people to 36% of Hmong people among Asian subgroups and from 17% of Fijian people to 43% of Marshallese people among NHOPI subgroups. Household composition also varied by subgroup. Among Asian subgroups, the share who were parents or living in multigenerational households ranged from 27% for Japanese people to 68% for Bhutanese people. Among NHOPI subgroups, Native Hawaiian people (27%) were less likely than the group overall to be in a multigenerational household, while Marshallese people were more likely (48%).

Health Coverage

As of 2021, among the nonelderly population, 6% of Asian people and 11% of NHOPI people were uninsured (Figure 3). The uninsured rate for Asian people was slightly lower than the rate for White people (7%), while the rate for NHOPI people was higher. Across both groups, uninsured rates were lower for children compared to nonelderly adults. The shares of Asian people covered by private coverage were higher than the shares for White people and the shares covered by Medicaid were lower. In contrast, NHOPI people were less likely to have private coverage and more likely to be covered by Medicaid, with over half (52%) of NHOPI children being covered by Medicaid or the Children’s Health Insurance Program (CHIP).

There are wide variations in uninsured rates among Asian and NHOPI subgroups (Figure 4). As of 2021, among nonelderly Asian people, uninsured rates ranged from 4% for Asian Indian and Taiwanese people to 28% for Mongolian people. Among NHOPI people, uninsured rates ranged from 5% for Chamorro people to 24% for Marshallese people, although uninsured rates for other NHOPI subgroups were not statistically significantly different from nonelderly NHOPI people overall. Uninsured rates further varied by citizenship status, with higher uninsured rates for noncitizens across most groups. Among nonelderly Asian noncitizens, uninsured rates varied from 5% for Japanese people to 38% for Mongolian people. There were no statistically significant differences in uninsured rates among nonelderly NHOPI noncitizens. Of note, the sample sizes for some noncitizen subgroups were small (<50), which can lead to a higher degree of uncertainty, i.e., larger confidence intervals for their measures. Confidence intervals for each subgroup measure in Figure 4 can be found in the Appendix.

Socioeconomic Differences

A variety of social and economic factors influence individuals’ access to health coverage, their ability to access health care, and their overall well-being. While as a broad group Asian people often fare similar to or better than White people across many of these measures, some subgroups fare worse. On the other hand, NHOPI people generally fare worse than their White counterparts across a range of social and economic measures.

Data show variations in socioeconomic measures among nonelderly Asian and NHOPI subgroups, which may contribute to the differences in health coverage (Figure 5). Among Asian subgroups, there was an almost five-fold difference in the share of people who have received a bachelor’s degree or higher, with 18% of Laotian people having a bachelor’s degree or higher as compared to 87% of Taiwanese people. Overall educational attainment is lower among NHOPI people, with a lower share of Marshallese people (6%) having a bachelor’s degree or higher compared to nonelderly NHOPI overall, and a higher of Chamorro people (28%) having at least a college degree. The share of Asian households with at least one full-time worker also varied by subgroup, ranging from 66% among nonelderly Mongolian people to 91% among nonelderly Asian Indian people. Among NHOPI people, Fijian and Samoan people were slightly more likely than the overall group to have at least one full-time worker. Similarly, household income among Asian subgroups varied widely with the share of nonelderly people who lived in a low-income household (below 200% of the federal poverty level or $43,920 for a family of 3 in 2021) ranging from 12% among Asian Indian people to 55% among Mongolian people and 52% among Burmese people. Some of these differences are likely driven by differences in citizenship and visa status. For example, those entering the U.S. with work visas likely have higher median household incomes compared to those that entered as asylees and/or refugees. Many Burmese people immigrate to the U.S. as refugees fleeing war in their home country, which could contribute towards their lower household incomes. On the other hand, higher earning groups such as Taiwanese people and Asian Indian people usually immigrate through work visas. Despite eight in ten nonelderly Marshallese people living in a household with at least one full-time worker, 63% lived in a low-income household, while only 27% of Chamorro and Fijian people were low-income. Lower educational attainment as well as higher shares of noncitizens may in part explain the higher shares of Marshallese people living in low-income households.

Key Issues Looking Ahead

Understanding the experiences of Asian and NHOPI people is of particular importance at this time given growing concerns about mental health and well-being amid a significant uptick in anti-Asian hate incidents. The COVID-19 pandemic and underlying racism and discrimination have contributed to a significant rise in hate crimes against Asian people in the United States, which have contributed to deteriorating mental health among Asian people. In a 2021 survey, a majority of Asian Americans cited COVID cases being first reported in China and President Trump as major reasons for discrimination against the Asian and Pacific Islander community. Against the backdrop of these anti-Asian sentiments and actions, two tragic mass shootings occurred around this past Lunar New Year, of whom many of the victims were Asian. These tragic events and their devasting impacts on the community have highlighted the importance of understanding and addressing mental health needs among Asian and NHOPI people. Although overall rates of mental illness are generally lower among Asian people compared to White people, this finding may reflect underdiagnosis and underreporting. It also may mask variations in mental health among subgroups of the population. Among people with mental illness, Asian people are less likely to utilize mental health services compared to other racial and ethnic groups. In 2021, among adults with any mental illness in the past year, only 25% of Asian adults reported receiving mental health services compared to 52% of White adults (Figure 6). Data on utilization were not available for NHOPI people. Moreover, data show rising rates of suicide death among Asian and Pacific Islander adolescents (ages 12-17). Although they have lower rates of suicide deaths compared to their White peers, suicides were the leading cause of death among Asian and Pacific Islander children ages 10-14 and the second leading cause among those between the ages of 15 and 35 in 2020, and suicide death rates more than doubled among this population from 2010 (2.2 per 100,000) to 2020 (5.0 per 100,000).

In the wake of the COVID-19 pandemic, there has been a heightened awareness and focus on addressing health disparities, including recognizing the ongoing impacts of historic actions and policies on health disparities today. Anti-Asian racism is not new within the United States. Anti-Asian sentiments and related Sinophobia are embedded in U.S. history, as evidenced by the implementation of the Chinese Exclusion Acts in the late 1800s and the incarceration of Japanese Americans in the twentieth century. Historical actions have also contributed to ongoing trauma and negative health outcomes for NHOPI people. In the 19^th century, the U.S. began substantial expansion across the Pacific Ocean which included the colonization of many of the Pacific Islands, and the overthrow of the Hawaiian monarchy. Since occupation, the United States’ colonial, post-colonial, and military actions in the region have resulted in adverse socioeconomic, health, and environmental pollution-related legacies among local and Indigenous populations. In addition to these historic actions and their aftermath, Asian and NHOPI people have faced ongoing stresses associated with the perpetual foreigner and model minority stereotypes, and acculturation.

The federal government has taken several actions focused on advancing health equity broadly and in response to the rise in Asian hate and anti-Asian violence, specifically. Early in his presidency, President Biden issued a series of executive orders focused on advancing health equity, including orders that outlined equity as a priority for the federal government broadly and as part of the pandemic response and recovery efforts. Federal agencies were directed with developing Equity Action Plans that outlined concrete strategies and commitments to addressing systemic barriers across the federal government. In 2021, Congress enacted the COVID-19 Hate Crimes Act in response to the increase in anti-Asian violence during the pandemic. During that time, the Biden Administration also released Executive Order 14031 “Advancing Equity, Justice, and Opportunity for Asian Americans, Native Hawaiians, and Pacific Islanders," which established the White House Initiative on Asian Americans, Native Hawaiians, and Pacific Islanders (WHIAANHPI). The WHIAANHPI is committed to advancing equity for Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) by investing in AANHPI communities and responding to the spikes in anti-Asian violence. In January 2023, the White House announced its National Strategy to Advance Equity, Justice, and Opportunity for Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) Communities.

As part of efforts to address disparities and advance health equity, there are efforts underway to expand and improve availability of disaggregated data, including for Asian and NHOPI people. As shown in this analysis, Asian and NHOPI people have diverse characteristics and experiences that influence their health and health care. These differences point to the importance of having disaggregated data for Asian and NHOPI groups to identify disparities and direct efforts to address them. The Biden Administration has charged the government with addressing the systemic lack of disaggregated AANHPI data in federal statistical systems. The Interagency Working Group on Equitable Data in collaboration with the WHIANHPI is also working to improve research on policy and program outcomes for AANHPI communities. In April 2022, the working group released its Equitable Data Working Group Report, which highlighted the need to generate disaggregated data, increase access to disaggregated data, conduct equity assessments of federal programs, and emphasize accountability to communities in the United States. The Office of Management and Budget released proposals in January 2023 to update the minimum standards for collecting and presenting data on race and ethnicity for all federal reporting, including providing a separate racial category for people who identify as Middle Eastern or North African and moving to collect race and ethnicity through a combined single question instead of asking about Hispanic or Latino ethnicity in a separate question from race.

Appendix

Figure 4a: Share of All Nonelderly Uninsured Asian People, 2021

Figure 4b: Share of Nonelderly Uninsured Asian Citizens, 2021

Figure 4c: Share of Nonelderly Uninsured Asian Noncitizens, 2021

Figure 4d: Share of All Nonelderly Uninsured NHOPI People, 2021

Figure 4e: Share of Nonelderly Uninsured NHOPI Citizens, 2021

Figure 4f: Share of Nonelderly Uninsured NHOPI Noncitizens, 2021

(Back to top)

A KFF survey of Medicaid enrollees largely fielded prior to states resuming their efforts to redetermine Medicaid enrollees’ eligibility reveals many enrollees are unprepared for the renewal process that could result in some losing their coverage either due to eligibility changes or paperwork issues.

During the COVID-19 pandemic, states suspended their Medicaid eligibility renewals in exchange for additional federal funding, ensuring continuous health coverage for enrollees. States recently have resumed eligibility renewals and as of April 1 could start to disenroll people who either no longer qualify or who do not complete the renewal process.

The survey found that nearly two-thirds (65%) of Medicaid enrollees were unsure whether states could remove people from the program if they no longer meet the eligibility requirements or don’t complete the renewal process. An additional small share (7%) incorrectly believe that states couldn’t do this.

More than four in 10 enrollees whose sole coverage is Medicaid say that if the state told them they were no longer eligible for Medicaid coverage, they would not know where to look for other coverage (27%) or end up uninsured (15%).

Other findings include:

• Nearly half (47%) of Medicaid enrollees say they have not previously been through the Medicaid renewal process, including two-thirds (68%) of Medicaid enrollees who are 65 and older. This group may be less likely to understand the importance of completing the renewal paperwork to maintain their coverage.

• A third (33%) of enrollees say they have not provided updated contact information to their state Medicaid agency in the past year. Some in this group may miss critical eligibility renewal notices that would require action on their part to maintain coverage.

• About half (52%) of enrollees say they prefer to get Medicaid information via the U.S. mail, which is the primary way most states contact enrollees, though nearly half of enrollees say they would prefer to get Medicaid information another way – through email (29%), an online portal (11%), or text messages (8%).

• About a third of Medicaid enrollees say they have had a change in income or other change that could now make them ineligible for Medicaid or are unsure if they have had such a change, but most enrollees (65%) say their circumstances have not changed, suggesting they are still eligible. Those who are still eligible could lose coverage if they don’t complete the renewal process.

• The vast majority (85%) say that it would be useful if they had a navigator to help with the renewal process and look for other coverage if needed.

Designed and analyzed by public opinion researchers at KFF, the survey was conducted February 21-March 14, 2023, online and by telephone among a representative sample of 3,605 adults in the U.S. with health insurance coverage, including 1,212 individuals with Medicaid coverage. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 4 percentage points for those with Medicaid coverage. For results based on other subgroups, the margin of sampling error may be higher.

During the COVID-19 pandemic, the U.S. population experienced the most significant two-year decline in life expectancy in roughly a century, according to new research by KFF, with data showing that COVID-19 deaths disproportionately impacted people of color and exacerbating longstanding racial disparities in life expectancy. While overall U.S. life expectancy declined by 2.7 years between 2019 and 2021, American Indian and Alaskan Native (AIAN) people experienced a decline of 6.6 years, Hispanic people and Black people dropped 4.2 and 4 years, respectively, compared to a decline of 2.4 years for White people and 2.1 years for Asian people

Cancer and heart disease continue to be the leading causes of death for the U.S. population and in 2020 COVID-19 joined them in the ranks, but the pandemic has coincided with other increases in causes of death. Liver disease rose to the ninth leading cause of death in 2021, reflecting a rise in alcohol-related deaths, with AIAN people experiencing the most significant increase in this cause of death.Increases in drug overdose deaths were a major factor in the rise of unintentional injury deaths from 2019 to 2021, although its ranking did not fluctuate much within racial groups.

While suicide’s ranking among the leading causes of death fell from 2019 to 2021, there was a significant increase in suicides among Black and White people and AIAN men.Provisional 2022 data indicate a decrease in overall mortality from 2021, reflecting declines in COVID-19 deaths overall. However, AIAN and Black people continue to have higher COVID-19 death rates than White people.Read the brief for a discussion about addressing underlying drivers of U.S. life expectancy racial disparities, including inequities in health insurance coverage, access to care, and social and economic factors that drive health.

A new KFF analysis reviews exceptions to abortion bans and describes how the stated aim to provide life-saving and health-preserving abortion care may not be achieved in practice. Abortion is currently banned in 14 states and many other states have attempted to ban or severely restrict abortion access. Exceptions to state abortion bans generally fall into four general categories: to prevent the death of the pregnant person, when there is risk to the health of the pregnant person, when the pregnancy is the result of rape or incest, and when there is a lethal fetal anomaly.

• While the state bans and restrictions include life or health exceptions, the vagueness of the language describing them can effectively restrict the ability of clinicians to exercise their own medical judgement based on their expertise and accepted standards of care.

• Abortion bans and restrictions have led physicians to delay providing miscarriage management care. 
• Mental health exceptions are rare even though 20% of pregnancy-related deaths are attributable to mental health conditions. 
• Few state abortion bans contain exceptions for pregnancies resulting from rape or incest and law enforcement involvement is often required to document the sexual assault. 
• In states where there is more than one abortion ban, the exceptions can be at odds with each other, creating confusion among patients and providers.  

Read the brief, “A Review of Exceptions in State Abortions Bans: Implications for the Provision of Abortion Services” to learn more about how exceptions to abortion bans impact access to abortion care for people across the United States.

Two new KFF analyses examine the potential impact of Medicare coverage of new prescription drugs for obesity and Alzheimer’s disease on program spending and beneficiary out-of-pocket costs, as well as the role that the Inflation Reduction Act could play in mitigating these effects.

Manufacturers of both types of drugs are lobbying for broad Medicare coverage of them, though they face different challenges.

The availability of effective weight-loss drugs, including Novo Nordisk’s Ozempic and Wegovy (semaglutide) and Eli Lilly’s Mounjaro (tirzepatide), has the potential to be transformative for people who struggle with obesity and obesity-related medical conditions. But, as the first analysis explains, these drugs, which are expensive, are not covered by Medicare because current law prohibits Medicare from covering drugs prescribed for weight loss. Congress would need to amend the law for weight-loss drugs to be covered under Medicare, though coverage could also potentially be achieved administratively through a demonstration waiver or a Center for Medicare and Medicaid Innovation model.

Without coverage, access to these relatively high-priced drugs will continue to be limited to people who can afford them, raising equity concerns. Wegovy, for example, has an estimated annual net price of $13,600. While Black Medicare beneficiaries have the highest rates of obesity, they may be least able to afford these new drugs, given their substantially lower incomes and assets compared with White beneficiaries.

In the fight against Alzheimer’s, the Food and Drug Administration will soon announce whether it will grant full approval to the new drug Leqembi (lecanemab), made by Eisai and Biogen, after granting accelerated approval in January. Our second analysis explains that, if that happens, Medicare is expected to cover Leqembi for all indicated populations. Medicare coverage of a drug that could slow the progression of cognitive decline offers hope for Alzheimer’s patients and their families. But it also raises concerns about the potential impact on Medicare spending.

The take-up rate of Leqembi among eligible individuals is difficult to estimate, but for illustrative purposes, if five percent of the 6.7 million older adults in the United States with Alzheimer’s disease were to take Leqembi, at the annual list price of $26,500, this would add an estimated $8.9 billion to Medicare Part B spending annually, roughly equal to spending on the top three Part B drugs combined in 2021. If double that share were to take the drug, the higher spending would amount to $17.8 billion. Higher spending would likely lead to higher Medicare Part B premiums.

Even if Medicare were to cover Leqembi, patients administered the drug would be responsible for 20 percent of the cost, or more than $5,000 out of pocket in cost sharing each year, unless they have coverage that covers a portion of these costs. With higher rates of dementia and lower incomes among older Hispanic and Black adults than among older White adults in the U.S., Black and Hispanic beneficiaries may be less likely to get this treatment if they can’t afford it.

If covered by Medicare, these drugs could be among the limited number of drugs that would be subject to Medicare’s new drug price negotiation authority under the Inflation Reduction Act – but not for several years. For example, manufacturers of biologic drug products like Leqembi would be exempt from having Medicare-negotiated prices take effect for 13 years from the drug’s licensure date, which for Leqembi itself would be no sooner than 2036. For one of the small-molecule drugs being used for weight loss, negotiated prices could potentially take effect in 2027.

Another provision of the law will cap out-of-pocket Part D spending at $2,000 in 2025. The cap would make weight loss drugs more affordable if they are covered under Part D, but the law’s new cap does not limit out of pocket spending for drugs that are covered under Medicare Part B, as would be the case with Leqembi.

For the full analyses, as well as more data and analyses about Medicare and prescription drugs, visit kff.org.

• “What Could New Anti-Obesity Drugs Mean for Medicare?”

• “New Alzheimer’s Drugs Spark Hope for Patients and Cost Concerns for Medicare”

This post has been updated to reflect the introduction of legislation in the 118th Congress in July 2023 that would authorize Medicare coverage of weight-loss medications.

A relatively new class of medications is generating excitement in the medical community and among people with obesity and others who struggle to lose weight. Initially approved to treat type 2 diabetes, these drugs, known as GLP-1 (glucagon-like peptide-1) agonists, including Novo Nordisk’s Ozempic and Wegovy (semaglutide) and Eli Lilly’s Mounjaro (tirzepatide), are also highly effective weight loss agents. But they are also expensive, and not covered by Medicare when used for weight loss. In this piece, we discuss Medicare coverage of obesity treatments, the potential cost implications if Medicare covers anti-obesity drugs, and how the Inflation Reduction Act could potentially address these cost concerns.

Medicare coverage of obesity services and treatments currently includes obesity screening, behavioral counseling, and bariatric surgery, but not drugs that are prescribed for weight loss. The 2003 law that established the Medicare Part D prescription drug benefit explicitly prohibits Part D plans from covering drugs used for weight loss, along with some other types of drugs, including agents used for cosmetic purposes or hair growth, fertility drugs, and drugs prescribed to treat sexual or erectile dysfunction.

With evidence that GLP-1s lead to significant weight loss and may offer additional health benefits to people with medical conditions exacerbated by excess weight, manufacturers of these drugs and other stakeholders are pushing for a change in law to allow coverage under Medicare. This push for expanded coverage under Medicare and other insurance plans is taking place despite some uncertainty about the risks associated with their use. A bipartisan group of lawmakers has introduced legislation, the Treat and Reduce Obesity Act, that would authorize Part D coverage of medications when used for the treatment of obesity or weight loss management in overweight individuals with related comorbidities.

Lifting the current law prohibition on coverage of weight-loss drugs would come at a cost to Medicare, given the high price and expected demand. Wegovy, for example, has an annual estimated net price of $13,600. According to a recent study, if 10% of Medicare beneficiaries with obesity use Wegovy, the annual cost to Medicare could be $13.6 billion (based on a 19% obesity rate from traditional Medicare diagnoses in 2021) to $26.8 billion (based on a 41.5% obesity rate from survey data for adults ages 60 and older). Higher take-up rates would mean higher Medicare spending. For context, total annual Part D spending in 2021 was $98 billion. Of note, these estimates do not account for potential reductions in Medicare spending that could occur if weight loss drugs reduce medical spending associated with other diseases, such as heart disease.

Maintaining the status quo, however, could raise both access and equity concerns, given the current price. The annual cost of Wegovy is unaffordable for many Medicare beneficiaries. Moreover, the rate of obesity is highest among Black Medicare beneficiaries compared to beneficiaries in other racial and ethnic groups (Figure 1). Without Medicare coverage, Black beneficiaries may be least able to afford these new drugs, given their substantially lower incomes and assets than White beneficiaries.

The Inflation Reduction Act of 2022 could help lessen the cost impact of weight loss drugs on Medicare and Part D enrollee out-of-pocket spending. If covered by Medicare, weight loss drugs could be among the limited number of drugs that will be subject to Medicare’s new drug price negotiation authority, but not for several years. At the earliest, a negotiated price for semaglutide, for example, would not be available before 2027 (based on FDA approval in late 2017) and not before 2031 for tirzepatide (based on FDA approval in 2022). Another provision would subject weight-loss drugs to the new law’s inflation rebate that aims to limit annual increases in drug prices. A third provision of the law will cap out-of-pocket Medicare Part D spending for covered drugs at $2,000 in 2025, which would certainly help to make these drugs more affordable. But even paying $2,000 out of pocket would still be beyond the reach of many people with Medicare who live on modest incomes.

To limit the potential cost impact to Medicare, lawmakers could consider shortening the period between FDA approval and the year negotiated prices take effect, as proposed in the Biden Administration’s FY2024 budget, but adopting this change to the newly-launched negotiation program seems unlikely in the current political climate. If the underlying Part D law is not changed, adding Medicare coverage for obesity drugs could possibly be achieved through other pathways, such as a demonstration program through the Centers for Medicare & Medicaid Innovation or Section 402 authority.

The availability of effective weight-loss drugs has the potential to be transformative for people who struggle with obesity and obesity-related medical conditions, but without insurance coverage, access to these relatively high-priced drugs will be limited to those who can afford them. While competition among GLP-1 medications could have a moderating effect on launch prices, the combination of intense demand and high prices for these treatments is likely to place tremendous pressure on Medicare spending if coverage is authorized, even in the wake of the prescription drug provisions in the Inflation Reduction Act. A decision to cover weight-loss drugs under Medicare could have ripple effects for employers and other payers if they follow Medicare’s lead.

Introduction

May 18, 2023 marked one year since a case of mpox (monkeypox) was identified in the United States as a part of a new multi-country outbreak in regions where it had not previously been endemic. As a result, the World Health Organization (WHO) declared the mpox outbreak to be a Public Health Emergency of International Concern (PHEIC) on July 23, 2022 and the U.S. declared a Public Health Emergency (PHE) on August 4, 2022. Unlike prior mpox outbreaks, most of those impacted were gay and bisexual men and other men who have sex with men, including those with HIV. Furthermore, the majority of those affected in the U.S. have been people of color.

After the deployment of vaccines and treatments last summer, coupled with growing awareness of the disease, cases began to decline and both the WHO and the U.S. government have since ended their emergency declarations or allowed them to expire. Still, while cases in the U.S. continue to remain low, public health officials have expressed concern that they could rise again this spring and summer; indeed, recently, there was a small but notable outbreak in Chicago, raising questions about whether this is a harbinger for what is to come.

This brief provides an overview of the impact of mpox in the U.S. one year later, the federal response to date, and discusses the future outlook.

The impact

The 2022 mpox outbreak was not evenly distributed across the US. The majority (52%) of cases have been concentrated in the four most populous states (CA, FL, NY, and TX) – disproportionate to their share of the total population — though all states, DC, and Puerto Rico have reported at least 3 cases. In addition, almost all cases have occurred among gay and bisexual men and other men who have sex with men, differing from prior outbreaks in endemic countries.

Data from the CDC  indicate that 99% of cases reported between May and July of 2022 were among men and of those, 94% were among men who had sexual contact with other men. In addition, within this group, those living with HIV have been especially hard hit. Among mpox cases with data available on HIV status, 41% were also HIV positive.

Additionally, people of color, particularly gay and bisexual men of color, have been disproportionately impacted by mpox. While Black people account for 12% of the US population, they account for 33% of mpox cases. Hispanic people account for 19% of the US population but 31% of mpox cases. There are also notable racial and ethnic disparities in deaths associated with mpox with almost all mpox deaths reported in the U.S. to date (92% of 38 deaths with available demographic data) being among Black and Latino people; some of this may have been driven by disproportionate access to mpox vaccines (see below). Further, 94% of those who died were HIV positive, not virally suppressed, and 40% were experiencing homelessness, pointing to overlapping and intersecting drivers of inequality.

Federal response to date

Coordination

After the first cases of mpox were identified in May of last year, the CDC and other agencies took initial response steps such as developing an updated case definition for mpox, providing guidance to states and other public health officials with respect to surveillance, reporting, and contact tracing, testing, vaccination, and coordinating with international partners. Some were critical  that the initial response was slow and early on there were substantial hurdles related to testing and vaccine supply and accessibility. In June of 2022, the White House announced a government-wide strategy including an approach to scaling up surveillance, vaccination and testing efforts, and the CDC activated its Emergency Operations Center to enhance operational support, including monitoring and coordination. The federal government also worked to educate health care providers and the public and identify research priorities.

Today, the federal response is coordinated by the National Mpox Response Office at the White House and involves coordination across the federal government, especially within the U.S. Department of Health and Human Services (HHS) and its operating divisions and offices. These include the Office of the Assistant Secretary for Preparedness and Response (ASPR, which includes the Strategic National Stockpile under the Office of Operations and Resources as well as the Biomedical Advanced Research and Development Authority (BARDA)), the Food and Drug Administration (FDA), Health Resources and Services Administration (HRSA), and the National Institutes of Health (NIH). The White House Office of Science and Technology Policy (OSTP) also plays a role.

Testing

Testing for mpox initially took place through the CDC and other public health laboratories and was very limited, creating access challenges for patients and providers. However, capacity ramped up and eventually expanded to commercial laboratories nationwide. Testing capacity grew from 6,000 tests per week in June of 2022 to 80,000 per week by July, with expansions largely due to CDC partnering with commercial laboratories. Because newer assays under emergency use authorization (EUA) are not included in this number, capacity is potentially larger today.

Vaccination

JYNNEOS, the preferred mpox vaccine used in the U.S., has been approved by the FDA for both smallpox and mpox, and is made available to jurisdictions through the Strategic National Stockpile. JYNNEOS, a two-dose regimen, can be used following a known or likely exposure (i.e., post-exposure prophylaxis or PEP) or as a preventive measure before an exposure occurs (i.e., pre-exposure prophylaxis or PrEP).

In the early days of the outbreak, HHS began shipping what was then a very limited supply of vaccines to states on May 21, 2022, using a four-tier distribution strategy that prioritized jurisdictions with the highest mpox case rates (the U.S. had just 65,000 JYNNEOS doses in the stockpile in late June 2022). Additional doses were ordered for the 2020-2023 period, with 6.9 million doses of JYNNEOS expected to be available by mid-2023, enough to vaccinate 3.5 million people. (See our prior analysis for more details.) Recent information suggest this timeline is on track as of March 2023. Today, a jurisdictional threshold approach is being used based on each jurisdiction’s estimated percentage of the nation’s population for whom JYNNEOS vaccination is recommended; jurisdictions can order any quantity of vials up to the threshold.

HHS also maintains a store of more than 100 million doses of the ACAM2000 vaccine, a smallpox vaccine considered effective for mpox, in the strategic national stockpile. However, due to its safety profile, JYNNEOS is the preferred vaccine.

Data on vaccine efficacy against disease ranged from 66% to 86% for two doses and from 36% to 75% for a single dose, depending on the study. A separate analysis of men aged 18-49 found that mpox incidence among those who were unvaccinated was 9.6 times higher than for those fully vaccinated and 7.4 times higher than among those with a single dose.

As of May 5, 2023 more than 1.2 million vaccine doses had been administered. However, just 38% of those vaccinated had been fully vaccinated. In addition, there are significant racial and ethnic disparities in vaccine uptake. Black and Hispanic people account for a smaller share of those with first dose vaccinations than their share of cases while White people have seen a lower case burden relative to their share of the population as a whole and a higher rate of vaccination (see Figure 1). A recent analysis by CDC found that vaccination is low among those at risk, defined as men who have sex with men who have an indication for HIV PrEP. Nationwide, just 23% of the population at risk is estimated to have been fully vaccinated, with significant variation across the country, ranging from just 5% in West Virginia to 67% in Washington, D.C.

Treatment

There are no available treatments that specifically target the mpox virus. However, because the smallpox and mpox viruses are similar, Ticoviromat (TPOXX), an antiviral approved for smallpox, is used to treat severe mpox cases. TPOXX is prescribed for mpox treatment under an expanded access Investigational New Drug (EA-IND) protocol and available from the strategic national stockpile at no cost. On July 1, 2022, HHS reported that the strategic national stockpile had over 1.7 million TPOXX antiviral treatment courses. Through January 2023, 6,832 patients with mpox has been treated with TPOXX.

Because TPOXX for mpox is only available under an EA-IND protocol through the CDC, access can be challenging. Initially, there were many reports of providers facing lengthy and burdensome processes in accessing treatment, creating a barrier for patients and a challenge for provider. In response CDC streamlined the approval process, though it still can take some time for providers to navigate.

In an effort to promote equitable access, jurisdictions can also request oral TPOXX using a threshold approach. TPOXX thresholds are formula driven: 75% is based on the number of jurisdictional cases and 25% on the number of individuals at the highest risk.

Federal Funding

New federal funding to address mpox has not been appropriated by congress, though the White House requested $4.5 billion in the FY23 omnibus spending bill.

Given the lack of new federal investment, agencies have had to use existing resources to fund response activities. For example, CDC has allocated funding to jurisdictions on two occasions through its Public Health Crisis Response Cooperative Agreement: once in December 2022 when $12.5 million was awarded to 21 jurisdictions for vaccination and other mpox response activities and again in January 2023 when $33.7 million was awarded to 53 jurisdictions to respond to remaining cases, prevent future outbreaks through vaccination efforts, and strengthen capacity to respond to future cases. In addition, several agencies, including the CDC and HRSA’s Ryan White HIV/AIDS Program, provided guidance around flexibilities to allow grantees to use existing funding to address mpox. Federal investments have also been directed to mpox research activities across a range of government programs/agencies.

Surveillance

In partnership with states and local jurisdictions, CDC plays the central federal role in mpox surveillance. Jurisdictions collect data which is then reported to and combined by the CDC. CDC then provides surveillance data and reports on a range of variables including:

• Cases, including by patient demographic and trends.
• Vaccination, including on administration, coverage, and effectiveness.
• TPOXX Treatment
• Wastewater surveillance

Public communication and partnerships

The communication to the public and providers around mpox has largely come out of CDC. HHS’ Office of Infectious Disease and HIV/AIDS Policy, the Health Resources Services Administration (HRSA) -  especially within the Ryan White Program - have also played a role.

CDC has provided public education materials to jurisdictions, providers, and individuals though webinars, website materials, and engagement at local events. This includes equity tool kits for local outreach and messaging specifically aimed at the hardest hit communities and communities of color in an effort to address racial/ethnic disparities. CDC also engaged with on the ground partners as part of its vaccine equity pilot project aimed at reducing vaccine inequalities). Applications are now closed but in total 28 applications from 14 states and Puerto Rico were accepted, grouped by two strategies: vaccination events developed to reach specific populations disproportionately affected and vaccination events with a broad reach (though still generally targeting hard hit communities). Examples for projects include events at Southern Decadence and Atlanta Black Pride to provide vaccines and education though community engagement and targeted messaging.

Communication from HHS’ Office of Infectious Disease and the Ryan White Program has focused on the syndemic nature of mpox, HIV, and other STIs. The Ryan White Program has provided education for providers and jurisdictions, flexibility with its grants to respond to mpox, and distributed vaccination through grantees dually funded by Ryan White and HRSA Health Centers.

(In addition, there have been several private sector efforts to address communications gaps such as the mpox education and awareness resources developed by KFF's Greater Than HIV program).

The Chicago outbreak and the future outlook nationwide

Overall mpox cases in the U.S. remain low but public health officials are monitoring whether there might be a surge of cases as we move into warmer months, a time often associated with more social gatherings and warned of a possible resurgence.

A recent outbreak in Chicago was reported via an alert from the city and raised concerns that this could occur. The alert stated that between mid-April and early May 2023, 13 confirmed or probable mpox cases had been identified in the city (compared to many weeks in February and March when the city reported no cases). Moreover, most cases were among those fully vaccinated, raising questions about vaccine effectiveness, and one-third were among virally suppressed people with HIV. Since this alert was published, more cases have been reported.

It is not yet known what the rest of the year will look like. There could be isolated local outbreaks as has occurred in Chicago or transmission could become more widespread, especially as vaccination lags in terms of initial uptake and second dose completion and potential wanning efficacy. On May 15, 2023, CDC released a Health Alert Network (HAN) message in response to the Chicago outbreak writing that the “spring and summer season in 2023 could lead to a resurgence of mpox as people gather for festivals and other events” and highlighting the important role vaccines play in potentially warding off more serious infection, even if full protection is not provided.

Separately, CDC estimates that if mpox is reintroduced and no additional risk mitigation occurs (i.e. vaccination or behavior changes), the risk of a resurgent outbreak is more than 35% in most jurisdictions and that such outbreaks could be large given that immunity among those most at risk is low.

Discussion

Overall, the public health system for addressing mpox in United States is in a markedly different place than it was one-year ago and is expected to be better able to respond should mpox cases rise. Additionally, providers are generally more knowledgeable about case identification and treatment and the communities most impacted have a better understanding of how to protect themselves, if cases climb.

However, disparities persist and those facing structural barriers and overlapping systems of discrimination -- including LGBTQ people, people of color, those with HIV, and people experiencing homelessness -- are particularly at risk. Building on lessons learned, including in terms of preparedness, coordination, engagement of hard-hit communities and leveraging an equity framework, will be important both to address lingering inequities today and to respond to potential future outbreaks tomorrow.

Jeannie Fuglesten Biniek, an Associate Director for the Program on Medicare Policy at KFF, testified before the Senate Homeland Security and Government Affairs Committee Permanent Subcommittee on Investigations on May 17, 2023 as part of a hearing on Examining Health Care Denials and Delays in Medicare Advantage. Her testimony describes what the Medicare Advantage market looks like today, the use of prior authorization by Medicare Advantage insurers, and gaps in data that limit oversight and the ability to understand and assess how the use of prior authorization impacts Medicare Advantage enrollees.