Jen Kates, Senior Vice President and Director of KFF’s Global Health & HIV Policy program presented “The End of the Public Health Emergency Declaration for COVID-19,” at the 2023 Preparedness Summit on April 24. The presentation describes key health-related flexibilities that will end because of the ending of the federal Public Health Emergency (PHE) declaration, as well as other emergency declarations and measures.

Zachary Levinson, Project Director of KFF’s Program on Medicare Policy, testified before the U.S. House of Representatives’ Committee on Ways and Means on April 26, 2023 as part of a hearing on Tax-Exempt Hospitals and the Community Benefit Standard. His testimony describes the value of tax exemption for hospitals, federal oversight of community benefits, concerns about the adequacy of government requirements, proposed policy solutions, and general tradeoffs of policies that seek to strengthen requirements for tax-exempt status.

A new KFF analysis finds that between 8 and 24 million people across the U.S. could be disenrolled from Medicaid during the unwinding of the program’s continuous enrollment provision.

The estimates draw on data collected through KFF’s recent survey of state Medicaid and CHIP officials, conducted with the Georgetown University Center for Children and Families. The survey focused on states’ eligibility and enrollment policies, and their approaches to the unwinding of pandemic-era protections that prevented states from disenrolling people from Medicaid during the public health crisis.  It included questions about how many people states estimate will lose Medicaid coverage in the months following the expiration of those protections in March.

Among states that responded to the survey, the midpoint estimate was that 18 percent would be disenrolled, suggesting that total Medicaid enrollment could fall by about 17 million people nationally during the unwinding, including 5 million children and 12 million adults. The new analysis offers three illustrative scenarios for how state-level Medicaid enrollment could decline between March 2023 and May 2024, ranging from 8 percent to 28 percent of total enrollees, which is plus or minus 10 percentage points from the midpoint and similar to the varying projections reported by states. While neither the lowest nor highest rate of disenrollment is an expected national outcome, the range may be helpful in examining what the variation could be across states.

The new findings are consistent with HHS estimates that as many as 15 million people will be disenrolled during the unwinding process, including 6.8 million who will likely still be eligible. (KFF’s analysis does not estimate how much of the Medicaid coverage loss would be among people who are still eligible versus those who are no longer eligible.)

The unwinding of the continuous enrollment provision will play out differently across the states based on policy choices states have made and variation in their administrative infrastructures. Some states have adopted multiple policies that are more likely to promote continued coverage among those who remain eligible. Other states have adopted fewer of these policies, which will likely lead to a larger number of people losing Medicaid coverage, including some who remain eligible.

According to another new KFF analysis, eight states meet at least eight of the nine key metrics that will support continued Medicaid coverage for those who remain eligible. Seven states meet only three or four of the metrics. The nine metrics come from the same survey of state Medicaid and CHIP officials and include things such as taking 12-14 months to complete all renewals, following up with enrollees who haven’t responded to a renewal request before terminating coverage, and completing 50 percent or more of renewals using ex parte, or automated, processes.

Among the 17 million children and adults who could be disenrolled from Medicaid, it remains uncertain how many will transition to other health coverage or become uninsured. A recent KFF analysis found that nearly two-thirds of people experienced a period of uninsurance after being disenrolled from Medicaid or the Children’s Health Insurance Program (CHIP).

The two new analyses, “How Many People Might Lose Medicaid When States Unwind Continuous Enrollment?” and “State Policy Choices Are Likely to Affect the Extent of Medicaid Enrollment Declines During the Unwinding Period,” as well as other data and analyses about the Medicaid unwinding, are available at kff.org.

Starting April 1, 2023 some states resumed disenrolling people from Medicaid after a three-year period during which states provided continuous enrollment in exchange for enhanced federal funding. Between February 2020 and March 2023, Medicaid enrollment grew by an estimated 20 million people, contributing to declines in the uninsured rate, which dropped to the lowest level on record in early 2022. As states unwind the continuous enrollment provision, we estimate, based on a recent KFF survey, that 17 million people could lose Medicaid coverage – including some who are no longer eligible and others who are still eligible but face administrative barriers to renewal. Decreases in Medicaid enrollment could reverse the recent gains in insurance coverage overall.

This analysis estimates the number of people who could lose Medicaid during the unwinding period under three possible rates of Medicaid coverage loss, and shows for each illustrative rate, state-by-state coverage reductions among Medicaid children and adults. In practice, rates of Medicaid coverage loss will vary across the states, depending on states’ approaches to the unwinding and the extent to which they engage in outreach and assistance activities to minimize disenrollment among people who are still eligible.

The analysis uses a combination of enrollment data from the Centers for Medicare and Medicaid Services (CMS) Performance Indicator Project (PI data), Medicaid claims data (T-MSIS data), and some state-specific sources (see Methods for a detailed explanation of the analysis). We exclude people enrolled in the Children’s Health Insurance program (CHIP) because it is expected that some of the people who disenroll from Medicaid will enroll in CHIP and CHIP enrollment may increase during the unwinding. (In some states, CHIP enrollment decreased during the continuous enrollment period, potentially because some people who were eligible for CHIP remained instead on Medicaid.)

Our estimates are based on the best available public data on states’ Medicaid enrollment, but predicting the future here with incomplete data is highly uncertain and the scenarios described in this data note are intended to be illustrative only. The scenarios presented here represent a range of outcomes that states predicted in the recent KFF survey, but the range reflects predictions reported across all states that responded to the question. The analysis excludes estimates of people who may newly enroll in Medicaid during the unwinding period and among those who disenroll, how many will re-enroll within a short time (e.g., “churn”). Our analysis projects the rate of disenrollment, but net changes in Medicaid enrollment—which reflect new enrollment and churn—will be smaller than the number of people who lose coverage.

How Many People Might Lose Medicaid?

If Medicaid enrollment decreased by 18% in all states between March 2023 and May 2024, as suggested by a recent KFF survey, 17 million would lose Medicaid coverage (Figure 1). In KFF’s recent survey of states about their Medicaid eligibility policies, just over one-third of states were able to report their projected coverage losses associated with the unwinding. The midpoint of state responses was that 18% of Medicaid enrollees could be disenrolled over the course of the unwinding, responses were quite varied, ranging from 7% to 33%. We use 18% for this analysis to illustrate how much enrollment could decrease. But, recognizing the uncertainty and the expected variation across states, we present disenrollment numbers if the rate is 10 percentage points above or below the median, a range of 8% to 28% which is similar to the range coming from state responses.

An 18% decline in enrollment would translate to 17 million people losing Medicaid, of whom 5 million are children and 12 million are adults. These projected coverage losses are consistent with estimates from the Department of Health and Human Services (HHS) suggesting that as many as 15 million people will be disenrolled, including 5 million children and 10 million adults. HHS estimates that among the 15 million people who lose coverage, nearly 7 million will still be eligible. (KFF’s analysis models disenrollment but does not attempt to estimate the number of people who are still eligible.)

Although the midpoint of states’ estimated disenrollment rate was 18%, rates will range considerably across the states. If rates range from 8% to 28%, 8 million to 24 million people could lose Medicaid, including 2 million to 7 million children and 5 million to 17 million adults (see Appendix Table 1 for state-specific estimates). While neither the lowest nor highest rate of disenrollment is an expected national outcome, the range may be helpful in examining what the variation could be across states.

Expected disenrollments during the unwinding could reverse more than half of the Medicaid enrollment gains experienced during the continuous enrollment period (Figure 2). Comparing the number of people who could lose Medicaid with estimated enrollment growth during the continuous enrollment period, shows that the number of people losing Medicaid coverage would be nearly three-quarters of the enrollment increase under the midpoint scenario. Under this midpoint scenario, just over one-quarter of the enrollment increase during the pandemic would persist, meaning Medicaid coverage would be higher than pre-pandemic levels. The higher-range estimate of Medicaid coverage loss—which is not expected to occur in most states—suggests that in some states, Medicaid disenrollments during the 14-month unwinding period could exceed the enrollment gains from the 3-year continuous enrollment period. In some states, the number of people losing Medicaid could exceed the coverage gains because all current Medicaid enrollees will have to go through a renewal process.

What Might Happen to the Uninsured Rate During the Unwinding?

As states resume renewals for all Medicaid enrollees, there is substantial uncertainty regarding how many people will lose Medicaid and of those, how many will transition to other coverage or become uninsured. A large share of people are covered by Medicaid, and one analysis shows that over half of children are covered by Medicaid and CHIP. Significant declines in Medicaid enrollment are likely to increase the number of uninsured, and other estimates suggest that there will be increases in the uninsured rate, in addition to increased enrollment in private health insurance and CHIP. The extent to which the uninsured rate may rise is difficult to predict based on current data sources. For example, because enrollment in Medicaid has been automatically sustained during the pandemic, it is possible that some people who are identified as enrollees with administrative data may have since transitioned to a job with employer-provided health coverage. And, federal surveys that are used to measure the uninsured rate – which rely on respondents self-reporting their health insurance status – show smaller increases in Medicaid enrollment than are observed in administrative data.

Even if people who disenroll from Medicaid are eligible for CHIP or for subsidies to purchase nearly-free private insurance through the ACA, they may not know they are eligible or transition to other coverage without a gap in coverage. Our recent analysis of coverage outcomes after disenrolling from Medicaid or CHIP found that nearly two-thirds of people experienced a period of uninsurance. Actual outcomes will vary across states depending on an array of state policy decisions. State efforts to provide outreach and enrollment assistance can help ensure that those who remain eligible for Medicaid—an unknown share of current enrollees—are able to retain coverage, and that those who are no longer eligible transition to other coverage.

Appendix Table

The Nation Overall Also Experienced Higher Rates of Premature Deaths than Peer Countries

During the COVID-19 pandemic, people of color on average died at younger ages than White adults, resulting in substantial racial disparities in premature death and years of life lost, a new analysis finds.

The analysis examines the Centers for Disease Control and Prevention’s excess deaths statistics during the pandemic, which captures not only deaths caused by COVID-19 but also higher-than-expected deaths from other causes such as drug overdoses, suicide, health disease and liver disease. 

During the pandemic, all racial and ethnic groups experienced an increase in their premature mortality rate (defined as per capita deaths among people under age 75), though this rate rose more sharply among people of color than among White people. 

Expressed another way, White people who died prematurely (under age 75) during the pandemic on average lost 12.5 years of life, significantly less than the average years lost among American Indian and Alaska Native (22), Hispanic (19.9), Native Hawaiian and Other Pacific Islander (18.8), Black (18.3), and Asian (14) people.  

Collectively, the analysis estimates that people in the United States lost 14.8 million years of life due to excess deaths from March 2020 when the pandemic began through December 2022, with a disproportionately large share of those lost years affecting people of color.A separate analysis compares the rates of premature deaths in the United States with other large and wealthy peer countries through 2021 (the most recent year for which international data are available). The U.S. had the highest rate of premature death among the group of 12 nations during the two-year period. The U.S. on average had more than two times the average years of life lost per 100,000 people as the United Kingdom, the country with the next highest rate. The two analyses, “Racial Disparities in Premature Deaths During the COVID-19 Pandemic” and “Premature Mortality During COVID-19 in the U.S. and Peer Countries,” are both available through the Peterson-KFF Health System Tracker, an information hub dedicated to monitoring and assessing the performance of the U.S. health system. 

This analysis examines changes in excess mortality and prematurity of those deaths in the U.S. and peer countries for 2020 and 2021. Using Centers for Disease Control and Prevention (CDC) weekly excess deaths data and the World Health Organization (WHO) all-cause excess death data, we compare excess mortality in the U.S. and other large and wealthy countries through 2021 and estimates the years of life lost, a measure of the prematurity of those excess deaths, during the COVID-19 pandemic. Excess deaths are the number of deaths beyond what would have been expected in a typical year and can be due directly or indirectly to COVID-19, as well as other causes.

When compared to other countries and adjusted for population size, the U.S. had the highest excess mortality rate among similarly large and wealthy countries for the period 2020-2021—the most recent data available for all these countries. In addition the U.S. also saw a higher rate of death among younger people, and thus a larger increase in premature deaths per capita than peer countries.

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

This analysis examines the impact of the COVID-19 pandemic by race and ethnicity through the lens of premature mortality, using the measures of premature mortality rate and years of life lost among excess deaths that occurred during the pandemic.

While the pandemic has had devastating effects across all racial and ethnic groups, we find significant racial disparities in premature death during the pandemic. Consistent with pre-pandemic trends, some communities of color faced higher premature death rates during the pandemic than their White counterparts. For all groups of color, though, the pandemic was associated with a steeper increase in the premature death rate than for White people.

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

On April 21st, the US Supreme Court blocked a lower court order that would have stopped the distribution and availability of the medication abortion drug, mifepristone, across the country. The high court’s ruling allows the current FDA rules to remain in effect, keeping mifepristone available for medication abortion where and when abortion is legal as the case proceeds through the courts. Telehealth abortions can also continue, where state law permits.

The court is responding to a ruling issued by Judge Matthew Kacsmaryk, the only judge in the US District Court for the Northern District of Texas Amarillo Division, who issued a preliminary injunction in the case, Alliance for Hippocratic Medicine v. FDA. The plaintiffs are challenging the FDA’s approval of mifepristone, one of the drugs used in medication abortion, claiming the FDA’s approval process and subsequent modifications of the conditions for dispensing mifepristone (known as REMS) as being beyond the FDA’s authority. The plaintiffs also contend that an 1873 anti-obscenity law, the Comstock Act, prohibits the mailing of any medication used for abortion (for details on the case see: Legal Challenges to the FDA Approval of Medication Abortion Pills).

Judge Kacsmaryk’s ruling would have blocked the FDA’s approval of mifepristone, which dates back to the year 2000. The judge delayed the enforcement of his own decision for seven days to give the FDA time to seek emergency relief from the U.S. Court of Appeals for the Fifth Circuit. The FDA and Danco Laboratories LLC (a party in the litigation, and the holder of the new drug application for Mifeprex, the brand name for mifepristone) appealed to Fifth Circuit Court of Appeals requesting a stay of Judge Kacsmaryk’s order pending the appeal (Figure 1). The Fifth Circuit Court of Appeals then issued an order which stayed part of the district court’s preliminary injunction (finding that the drug’s approval could not be revoked) but blocked the implementation of the changes that the FDA had made in 2016 to modify the agency’s conditions on the provision and dispensation of the drug (REMS). This decision would have effectively required the conditions that the FDA had in place 2011 to be re-introduced, taken the generic alternative drug off the market (GenBioPro), and required a relabeling of the drug. In addition, it would have required the drug to only be dispensed in person by a doctor, blocking the current ability of abortion providers and pharmacies to mail the drug.

On April 14, 2023, the FDA and Danco filed an emergency appeal with the Supreme Court, requesting either a stay of the district court’s ruling pending the appeal or for the Supreme Court to take the AHM case on an expedited basis. Later that day, Justice Alito, the justice assigned to emergency requests from the Fifth Circuit, issued an administrative stay keeping mifepristone available without any changes until April 19, 2023, which was subsequently extended to April 21, 2023.

On April 21, 2023, the Supreme Court blocked the district court’s ruling, sending the case back to the US Court of Appeals for the Fifth Circuit. Access to mifepristone will not change while this litigation continues through the final decision of the Supreme Court if their review is sought again.

It is important to recognize that this Supreme Court ruling is the not Court’s final word on the availability of mifepristone. The high court has sent this back to the Fifth Circuit to consider the appeal of the preliminary injunction (that is, the temporary block on mifepristone’s approval by Judge Kacsmaryk). The Fifth Circuit Court has scheduled an expedited hearing of the case for May 17, 2023, which will be the next step for this case. Procedurally, the Fifth Circuit is only considering the FDA and Danco’s appeal of the district court’s decision to temporarily block the FDA’s approval of mifepristone while the litigation proceeds. The district court has not yet considered the case on the merits. In the meantime, access to mifepristone will remain where abortion is permitted by state law.

The Inflation Reduction Act of 2022 includes several provisions to lower prescription drug costs for people with Medicare and reduce drug spending by the federal government, including a number of changes to the Medicare Part D drug benefit. These changes include a cap on out-of-pocket drug spending for enrollees in Medicare Part D plans and requiring Part D plans and drug manufacturers to pay a greater share of costs for Part D enrollees with high drug costs. This brief provides an overview of the Part D benefit design and Part D enrollee cost-sharing requirements in 2023 and changes coming in 2024 and 2025.

What Does the Medicare Part D Benefit Look Like in 2023?

The standard design of the Medicare Part D benefit currently has four distinct phases, where the share of drug costs paid by Part D enrollees, Part D plans, drug manufacturers, and Medicare varies (Figure 1). (The Part D enrollee shares reflect costs paid by enrollees who are not receiving low-income subsidies.)

• In the deductible phase, Part D enrollees pay 100% of their drug costs, up to $505 in 2023. Not all Part D plans charge a deductible, but many enrollees in stand-alone PDPs are in a plan that charges the standard deductible in 2023.
• In the initial coverage phase, Part D enrollees pay 25% of total drug costs and Part D plans pay 75%, up to total drug costs of $4,660 in 2023. However, most Part D plans charge a mix of copayments and coinsurance in this phase rather than a standard 25% coinsurance rate.
• In the coverage gap phase, Part D enrollees pay 25% of total drug costs for both brand-name and generic drugs. Part D plans pay the remaining 75% of generic drug costs and 5% of brand drug costs, and drug manufacturers provide a 70% price discount on brands (there is no manufacturer price discount on generics).
• In the catastrophic phase, Medicare pays 80% of total drug costs (known as “reinsurance”), Part D plans pay 15%, and Part D enrollees pay 5%. Part D enrollees qualify for catastrophic coverage when the amount that they pay out of pocket plus the value of the manufacturer discount on the price of brand-name drugs in the coverage gap phase exceeds a certain threshold amount. In 2023, the catastrophic threshold is set at $7,400, and enrollees themselves will pay about $3,100 out of pocket before reaching the catastrophic phase (this estimate is based on using brand drugs only).

How Is the Medicare Part D Benefit Changing in 2024?

In 2024, costs in the catastrophic phase will change: the 5% coinsurance requirement for Part D enrollees will be eliminated and Part D plans will pay 20% of total drug costs in this phase instead of 15%.

The 5% coinsurance requirement for Part D enrollees in the catastrophic phase will be eliminated

In 2024, once Part D enrollees without low-income subsidies (LIS) have drug spending high enough to qualify for catastrophic coverage, they will no longer be required to pay 5% of their drug costs, which in effect means that out-of-pocket spending for Part D enrollees will be capped. In 2024, the catastrophic threshold will be set at $8,000. This amount includes what Part D enrollees spend out of pocket plus the value of the manufacturer price discount on brands in the coverage gap phase. At this amount, Part D enrollees who take only brand-name drugs in 2024 will have spent about $3,300 out of their own pockets and will then face no additional costs for their medications.

To understand the impact of this change, it helps to consider what Part D enrollees without LIS currently pay for high-cost medications. For example, for the five drugs with the highest per capita Part D expenditures in 2021 used by more than 10,000 Part D enrollees – Revlimid, Pomalyst, Imbruvica, Jakafi, and Ibrance, all cancer treatments – annual out-of-pocket costs per drug in 2023 range from over $11,000 to nearly $15,000, and out-of-pocket costs for each drug in the catastrophic phase alone range from around $8,000 to nearly $12,000 (see methods for details) (Figure 2). (These estimates exclude the cost of other drugs that users of these drugs might be taking.) Eliminating the 5% coinsurance requirement in the catastrophic phase in 2024 means that Part D enrollees without LIS who use these or other high-cost medications covered by Part D will see thousands of dollars in savings.

Part D plans will pay a somewhat larger share of total drug costs above the catastrophic threshold

With the elimination of the 5% coinsurance requirement for Part D enrollees in the catastrophic coverage phase, Part D plans will be required to pay 20% of total drug costs in this phase in 2024, up from 15% in 2023 and prior years.

How Is the Medicare Part D Benefit Changing in 2025?

Changes in 2025 include a new $2,000 out-of-pocket spending cap, elimination of the coverage gap phase, a higher share of drug costs paid by Part D plans in the catastrophic phase, along with a new manufacturer price discount and reduced liability for Medicare in this phase, and changes to plan costs and the manufacturer price discount in the initial coverage phase.

Out-of-pocket drug spending will be capped at $2,000

Beginning in 2025, Part D enrollees’ out-of-pocket drug costs will be capped at $2,000. This amount will be indexed to rise each year after 2025 at the rate of growth in per capita Part D costs. (This cap does not apply to out-of-pocket spending on Part B drugs.)

For Part D enrollees who take only brand-name drugs, annual out-of-pocket costs at the catastrophic threshold will fall from around $3,300 in 2024 to $2,000 in 2025 (Figure 3). In other words, Part D enrollees who take only brands and have drug costs high enough to reach the catastrophic threshold could see savings of about $1,300 in 2025 relative to what they will spend in 2024.

The coverage gap phase will be eliminated

The coverage gap phase, where Part D enrollees had faced 100% of their total drug costs under the original Part D benefit design and currently face 25% of costs for brand and generic drugs, will be eliminated in 2025. This means that Part D enrollees will no longer face a change in their cost sharing for a given drug when they move from the initial coverage phase to the coverage gap phase, which is the case in most Part D plans today, since most plans charge varying cost-sharing amounts, rather than the standard 25% coinsurance, in the initial coverage phase.

Part D plans and drug manufacturers will pay a larger share of costs for catastrophic coverage, and Medicare will pay a smaller share

Medicare’s share of total costs in the catastrophic phase (reinsurance) will decrease from 80% to 20% for brand-name drugs and from 80% to 40% for generic drugs beginning in 2025. This reduction will help address concerns about the substantial increase in Medicare’s reinsurance payments to Part D plans over time, which accounted for close to half (48%) of total Part D spending in 2022, up from 14% in 2006, based on data from the Medicare Trustees 2023 annual report. Medicare Part D plans’ share of costs will increase from 15% to 60% for both brands and generics above the cap, and drug manufacturers will be required to provide a 20% price discount on brand-name drugs (Figure 4).

Part D plans and manufacturers will face changes to their share of total drug costs paid in the initial coverage phase

Drug manufacturers will be required to provide a 10% discount on brand-name drugs in the initial coverage phase beginning in 2025, replacing the 70% price discount in the coverage gap phase under the current benefit design. Part D plans will pay 65% of brand-name drug costs.

What Other Changes Are Being Made to Part D?

• As of 2023, the out-of-pocket cost of insulin products is limited to no more than $35 per month in all Part D plans. In addition, adult vaccines covered under Part D, such as the shingles vaccine, are covered with no cost sharing.
• Starting in 2024, people with Medicare who have incomes up to 150% of poverty and resources at or below the limits for partial low-income subsidy benefits will be eligible for full benefits under the Part D Low-Income Subsidy (LIS) Program. The law eliminates the partial LIS benefit currently in place for individuals with incomes between 135% and 150% of poverty.
• Also starting in 2024, the calculation of the base beneficiary premium will be adjusted, as needed, to limit increases in the base premium to no more than 6% from the prior year. (Premiums for individual Part D plan premiums and annual plan-level premium increases will continue to vary, however.)
• Starting in 2025, Part D enrollees will have the option of spreading out their out-of-pocket costs over the year rather than face high out-of-pocket costs in any given month.