A version of this brief with information for 2023 is available: Key Facts About Medicare Part D Enrollment and Costs in 2023

The Medicare Part D program provides an outpatient prescription drug benefit to older adults and people with long-term disabilities in Medicare who enroll in private plans, including stand-alone prescription drug plans (PDPs) to supplement traditional Medicare and Medicare Advantage prescription drug plans (MA-PDs) that include drug coverage and other Medicare-covered benefits. This analysis provides the latest data about Medicare Part D enrollment and costs in 2022 and trends over time, based on data from the Centers for Medicare & Medicaid Services (CMS).

Enrollment in Medicare Advantage drug plans has surpassed stand-alone prescription drug plan enrollment

A total of 48.9 million people with Medicare are currently enrolled in plans that provide the Medicare Part D drug benefit, including plans open to everyone with Medicare (stand-alone PDPs and MA-PDs), and plans for specific populations (retirees of a former employer or union and Medicare Advantage Special Needs Plans, or SNPs).

In 2022, more than half of all Part D enrollees (53%, or 25.8 million) are enrolled in MA-PDs and 47% (23.1 million) are enrolled in stand-alone PDPs—the first year that MA-PD enrollment has surpassed PDP enrollment (Figure 1, Table 1). Over time, Part D enrollment in MA-PDs has increased, reflecting enrollment growth in Medicare Advantage plans overall, while enrollment in PDPs has decreased each year since 2019. Between 2019 and 2022, the number of MA-PD enrollees increased by 34%, while enrollment in PDPs decreased by 8%.

Part D enrollment is concentrated in 3 national firms – UnitedHealth, Humana, and CVS – which have a combined 57% of total enrollment

The top three firms – UnitedHealth, Humana, and CVS Health – cover close to 6 in 10 of all beneficiaries enrolled in Part D in 2022 (57%), while the top five firms – including Centene and Cigna – account for three-quarters of Part D enrollment (Figure 2). These shares are unchanged from 2021.

Apart from Kaiser Permanente, which exclusively offers MA plans, the top Part D plan sponsors offer both stand-alone PDPs and MA-PDs. For most firms, Part D enrollment is more concentrated in one market than the other; for example, CVS Health, Centene, and Cigna have greater enrollment in PDPs than MA-PDs, while UnitedHealth and Humana have higher MA-PD enrollment than PDP enrollment (Figure 3).

Nearly 6 in 10 beneficiaries receiving the Part D Low-Income Subsidy are enrolled in Medicare Advantage drug plans

In 2022, 12.8 million Part D enrollees (26% of all Part D enrollees) receive premium and cost-sharing assistance through the Part D Low-Income Subsidy (LIS) program. These additional financial subsidies, also called “Extra Help,” pay Part D premiums for eligible beneficiaries (as long as they enroll in stand-alone PDPs designated as premium-free “benchmark” plans) and reduce cost sharing. LIS enrollment in MA-PDs has been steadily increasing, and now totals 7.3 million, or 57% of all LIS enrollees (Figure 4, Table 1).

As part of increased enrollment in MA-PDs, close to one-third of all LIS enrollees (32%) are now enrolled in Medicare Advantage Special Needs Plans (SNPs), up from only 4% in 2006. Overall, 4.6 million Medicare beneficiaries are enrolled in SNPs in 2022. SNPs limit enrollment to beneficiaries with certain characteristics, including those with certain chronic conditions (C-SNPs), those who require an institutional level of care (I-SNPs), and those who are dually enrolled in Medicare and Medicaid (D-SNPs), which account for the majority of SNP enrollees.

The average monthly premium for PDPs is substantially higher than the premium for drug coverage in MA-PDs

In 2022, the enrollment-weighted average monthly premium for PDPs is $40, a 4% increase from the weighted average PDP premium in 2021 ($38). The average monthly PDP premium is substantially higher than the enrollment-weighted average monthly portion of the premium for drug coverage in MA-PDs ($11 in 2022). Lower average premiums for Part D coverage in MA-PDs are mainly due to the ability of MA-PD sponsors to use rebate dollars from Medicare payments to lower or eliminate their Part D premiums. The total average premium for MA-PDs, including all Medicare-covered benefits, is $18 per month in 2022.

The calculation of the average monthly premium for Part D coverage in MA-PDs is relatively low because it includes the 69% of MA-PD enrollees in plans that do not charge a monthly premium in 2022. By comparison, all PDPs charge a monthly premium (although Part D enrollees who are receiving the full Part D Low-Income Subsidy and are enrolled in a benchmark PDP pay no monthly premium). The average enrollment-weighted premium for Part D coverage across the 31% of MA-PD enrollees in plans that charge a monthly premium is $35, which is within a few dollars of the average monthly premium for PDPs (Figure 5).

The average Part D deductible has increased for PDPs, while decreasing for MA-PDs; the 2022 weighted average annual drug deductible is 4.5 times larger in PDPs than in MA-PDs

In 2022, a large majority of PDP enrollees (86%) are in plans that charge a deductible, with nearly 8 in 10 (79%) in PDPs that charge the standard amount of $480 in 2022. Conversely, 1 in 5 MA-PD enrollees are in plans that charge the standard Part D deductible, and just over half (51%) are in plans that charge no drug deductible. These enrollment patterns explain the wide divergence between PDPs and MA-PDs in the enrollment-weighted average Part D deductible amount. For PDPs, the average Part D deductible in 2022 is $398, nearly 4.5 times larger than the average drug deductible in MA-PDs ($90) (Figure 6).

Most Part D enrollees face low copays for generic drugs, higher copays for preferred brands, cost sharing up to $100 or 50% for non-preferred drugs, and 25-33% coinsurance for specialty drugs

Most Part D enrollees pay low or no copayments for preferred generic drugs, but higher copays for generics not on the preferred tier. Over half of Part D enrollees (both PDP and MA-PD enrollees) pay $0 for preferred generics in 2022, but many pay $10 or more per prescription for generics that are not on the preferred tier (Figure 7). For these generic drugs, most PDP enrollees (76%) pay less than $10, while just over half of MA-PD enrollees (54%) pay between $10 and $20.

For preferred brands, virtually all MA-PD enrollees and two-thirds of PDP enrollees are in plans that charge copayments instead of coinsurance. Roughly two-thirds of MA-PD enrollees (68%) and 28% of PDP enrollees face copayments for preferred brands of $45 to $47, which is the maximum copayment amount permitted by CMS for preferred brand drugs. Another one third of PDP enrollees (34%) are in plans that charge a coinsurance for preferred brands of less than 25%, while only 1% of MA-PD enrollees pay a coinsurance for preferred brands.

For non-preferred drugs, most MA-PD enrollees (89%) are in plans that charge copayments while virtually all PDP enrollees are in plans that charge a coinsurance. For drugs on the non-preferred tier, which can be all brands or a mix of brands and generics, nearly half (49%) of all MA-PD enrollees are in plans that charge $100, the maximum copayment amount allowed by CMS for non-preferred drugs. More than half (57%) of PDP enrollees are in plans than charge 40% to less than 50% for non-preferred drugs and 11% of PDP enrollees are in plans that charge a 50% coinsurance rate, the maximum coinsurance allowed.

A larger share of MA-PD enrollees than PDP enrollees are in plans that charge the maximum 33% coinsurance rate for specialty tier drugs. For specialty tier drugs, defined by CMS as those that cost at least $830 per month in 2022, a much larger share of enrollees in MA-PDs (63%) than PDPs (14%)  are in a plan that charges the maximum 33% coinsurance, while a much larger share of enrollees in PDPs (79%) than MA-PDs (4%) are in a plan that charges the minimum 25% coinsurance. Plans that waive some or all of the standard deductible – which is the case for most MA-PDs – are permitted to set the specialty tier coinsurance rate above 25%.

It is important to note that for this analysis, we did not compare which specific drugs are covered on each tier in PDPs and MA-PDs, which, in addition to the cost-sharing amounts that plans charge, would also influence enrollees’ out-of-pocket costs. Given the different cost-sharing structures adopted by MA-PDs and PDPs, particularly for non-preferred drugs, it can be difficult to compare the actual out-of-pocket costs that beneficiaries would face for different types of drugs across plan types. It can also be difficult to know how a coinsurance rate will translate into actual out-of-pocket costs without knowing the underlying list price of a drug.

Juliette Cubanski is with KFF. Anthony Damico is an independent consultant.

Larry Levitt writes about the political and practical impact of the health care provisions in the Inflation Reduction Act  in The New York Times guest essay, “The Biggest Health Care Reform in a Decade Could Lower Your Costs.”

Please view an updated look at national and state data.

On August 4, 2022, the U.S. Department of Health and Human Services declared the U.S. monkeypox outbreak to be a public health emergency. The Centers for Disease Control and Prevention (CDC) recently released data on monkeypox cases reported in the U.S through July 22, including demographic data where available. Overall, these data show that, among U.S. cases with data available, nearly all were among men (99%) who reported recent male-to-male sexual or close intimate contact (94%). Additionally, as was the case with COVID-19, the early data show that Black and Hispanic people are bearing a disproportionate burden of monkeypox cases to date.

Data from 43 states and DC and Puerto Rico show that Black people made up 26% of cases compared to 12% of the population and Hispanic people accounted for 28% of cases versus 19% of the population. Data were not separately reported for American Indian and Alaska Native or Native Hawaiian or Other Pacific Islander people. CDC notes that areas with high numbers of cases that did not submit case reports are more racially and ethnically diverse. As such, the reported data may understate disparities. Moreover, the share of cases among Black people has risen in recent weeks, suggesting widening disparities for this group.

To date, race and ethnicity data is missing for the majority of monkeypox cases. CDC reports a total of 2,891 cases through July 22 in the 43 reporting states and DC and Puerto Rico. Case reports with at least some demographic data were available for 1,195 or 41% of these cases but only 1,095 or 38% of cases had race/ethnicity reported. Cases have continued to climb since the report, with CDC reporting over 10,000 cases as of August 11, 2022. As the COVID-19 pandemic highlighted, having comprehensive data disaggregated by race/ethnicity is necessary to identify and address disparities.

Overall, these early data highlight the importance of centering equity in monkeypox response efforts, including prevention, testing, and treatment, from the outset. Moreover, addressing challenges that include homophobia, stigma, and discrimination will be key given the disproportionate impacts among men who have sex with other men. Underlying structural inequities place people of color at increased risk for public health threats, as was seen in COVID-19 and as is beginning to be observed amid the monkeypox outbreak. Early and intentional efforts will be key to minimizing and preventing disparities going forward amid the monkeypox outbreak and for future public health threats.

President Biden signed the Inflation Reduction Act of 2022 into law on August, 16, 2022. KFF has several analyses relevant to understanding the health provisions in the legislation, as well as their potential impact on people.

Among other measures, the legislation for the first time requires the HHS Secretary to negotiate prices for some top-selling drugs covered in Medicare. It also requires drug companies to pay rebates if prices rise faster than inflation for drugs used by Medicare beneficiaries. And it caps out-of-pocket drug spending for beneficiaries in Medicare Part D at $2,000 annually.

The bill also extends for three years the enhanced Affordable Care Act subsidies that Congress passed last year as part of the American Rescue Plan Act. That temporary boost increased the amount of financial help available to people already eligible to buy subsidized health plans in the ACA Marketplaces, and expanded subsidies to more middle-income people, many of whom were previously priced out of coverage.

Medicare prescription drug provisions

• What Are the Prescription Drug Provisions in the Inflation Reduction Act?
• How Will the Prescription Drug Provisions in the Inflation Reduction Act Affect Medicare Beneficiaries?
• Polling: The Public Weighs In On Medicare Drug Negotiations
• Polling: Strategies to Lower Drug Costs Top the Public’s Health Priorities for Congress

ACA subsidies

• Five Things to Know about the Renewal of Extra Affordable Care Act Subsidies in the Inflation Reduction Act

As part of the Inflation Reduction Act, the Senate recently passed a three-year extension (through 2025) of enhanced subsidies for people buying their own health coverage on the Affordable Care Act Marketplaces. These temporary subsidies were originally slated to last two years (2021 and 2022) and were passed as part of the American Rescue Plan Act (ARPA). The enhanced subsidies increase the amount of financial help available to those already eligible and also newly expand subsidies to middle-income people, many of whom were previously priced out of coverage.

Here’s what to know about the likely renewal of these subsidies:

If signed into law, the Inflation Reduction Act will prevent steep increases in Marketplace premium payments

If Congress extends the temporary subsidies, as appears likely, premium payments in 2023 will hold mostly flat for Marketplace enrollees, since the premium tax credits shelter enrollees from increases in the underlying premium. The passage of the Inflation Reduction Act will extend temporary subsidies, preventing out-of-pocket premium payments from rising across the board next year for virtually all 13 million subsidized enrollees. In the 33 states using HealthCare.gov, premium payments in 2022 would have been 53% higher (more than $700 per year more) on average if not for these enhanced subsidies. The same is true in the states operating their own exchanges. Exactly how much of a premium increase enrollees would have seen in the absence of the Inflation Reduction Act would have depended on the enrollee’s income, age, and the premiums where they live.

For example, using our subsidy calculator, you can see that with the ARPA a 40-year-old couple making $25,000 per year currently pays $0 for a silver plan premium with significantly lowered out-of-pocket deductible costs. That would continue to be true under the Inflation Reduction Act, which continues the ARPA subsidies without interruption for three more years. Using a new version of our subsidy calculator that shows what premium payments in each zip code would have been if the ARPA had not passed, you can see that same couple would have paid $76 per month (or $915 over the course of 2022) without the ARPA. With the Inflation Reduction Act, though, this low-income couple would save $915 per year.

Here’s another example using the new calculator: In the absence of these enhanced subsidies, a 60-year-old couple with an income of $70,000 would have had to pay $1,859 per month (or $22,307 over the course of 2022) for a full-price silver plan. Now, compare this to our 2022 calculator that shows what they currently pay with the ARPA: The same couple currently pays $496 per month (or $5,950 over the course of the year), and would continue to pay a similar amount under the Inflation Reduction Act. Instead of being expected to pay about 32% of their income on insurance, which would likely be unaffordable, the couple is paying 8.5% of their income with enhanced subsidies. So, if Congress passes the Inflation Reduction Act, this older middle-income couple will save over $16,000 per year.

Related: See how 2022 premium payments would increase without the ARPA COVID-19 relief law’s enhanced tax credits. Click the images below to access two versions of the calculator.

The Double Whammy: How 2023 Premium Increases and Subsidy Expiration Would Have Affected Some Enrollees

The Inflation Reduction Act’s renewal of these enhanced subsidies would also prevent some enrollees from experiencing two kinds of premium increases at once. If Congress had allowed enhanced subsidies to expire, the subsidy cliff would have returned, meaning people with incomes over four times poverty (or about $51,520 for a single person) would lose subsidy eligibility altogether. So, without the Inflation Reduction Act, these enrollees would not only pay the increase due to the loss of subsidies, but also any increase in the underlying premium.

Our early look at 2023 premiums shows premiums rising about 10%, with most rate increases falling between about 5% and 14%. This is more than in past years, in part due to inflation and rebounding utilization. These rates are still proposed and will be finalized this month.

The figure below shows a hypothetical subsidy cliff if premiums do indeed rise by 10%. For example, a 60-year-old making just above four times poverty ($51,521) in 2022 pays 8.5% of their income on a silver plan with enhanced subsidies, but would have paid 22% of their income in 2022 without these subsidies on average across the U.S. If not for the Inflation Reduction Act, and if premiums rise 10% in 2023, this person would pay 24% of their income in 2023.

In the states where premiums are currently highest, people losing subsidies would have seen the steepest increases without the Inflation Reduction Act’s continuation of these enhanced subsidies. For example, a 60-year-old making just above four times poverty ($51,521) in 2022 would have paid more than a third of their income on a silver plan without subsidies in West Virginia and Wyoming; and in New Hampshire, the person would have paid 15% of their income without subsidies.

The Ticking Clock: Why the Timing Matters

The timing of the Inflation Reduction Act matters for insurers, regulators, and administrators of state and federal Marketplaces. Insurers are now in the process of finalizing 2023 premiums and some are already factoring in an additional premium increase because they expect ARPA subsidies to expire.

The National Association of Insurance Commissioners (NAIC) wrote to Congress asking to extend these subsidies by July to provide greater certainty as insurers set premiums for next year.

States and the federal government, which operates HealthCare.gov, will need to reprogram their enrollment websites and train consumer support staff on policy changes months ahead of open enrollment this fall.

The End of the Public Health Emergency: How Enhanced Marketplace Subsidies Could Mitigate Coverage Loss

The end of the public health emergency and, with it, the requirement for continuous enrollment in Medicaid is expected to lead to significant coverage losses. So far, the number of uninsured people has not grown during the pandemic and resulting economic crisis. However, ironically, we could see a jump in the uninsured rate as the public health emergency ends if people disenrolled from Medicaid do not find alternative coverage.

With the passage of the Inflation Reduction Act, the enhanced Marketplace subsidies could act as a bridge between Medicaid and the ACA Marketplaces when the public health emergency ends. If enhanced Marketplace subsidies are still in place when the Medicaid maintenance of eligibility (MOE) ends, many people disenrolled from Medicaid could find similarly low-cost coverage on the ACA Marketplaces. If they are eligible for Marketplace subsidies, people losing Medicaid coverage may find Marketplace plans that, like Medicaid, have zero (or near-zero) monthly premium requirement.

The Costs: What This Means for the Federal Budget

Although the Congressional Budget Office (CBO) has not yet released a final score of the Inflation Reduction Act, an early CBO estimate pegged the cost of a permanent extension of enhanced subsidies at about $25 billion per year. The Inflation Reduction Act extends these subsidies for three years (through 2025) – not permanently – though it is likely the average annual cost could be similar. A large part of the estimated cost is due to the CBO’s expectation that millions more people would enroll in the ACA Marketplaces than would if the enhanced subsidies are not extended. The actual cost will depend on how many people enroll and how much premiums rise over the coming years.

Conclusion

Health sector inflation, rising utilization, and other factors may cause 2023 premiums to rise by more than in past years. However, as we’ve written before, Congress’s action to extend the ARPA subsidies through the Inflation Reduction Act will have an even greater influence over how much subsidized ACA Marketplace enrollees pay out-of-pocket for their premiums than will market-driven factors that affect the underlying premium.

Whether subsidies expire at the end of this year or in two or three years, their expiration would result in the steepest increase in out-of-pocket premium payments most enrollees in this market have seen. Because the Inflation Reduction Act extends the enhanced subsidies for three years and not permanently, future Marketplace enrollees may see steep premium increases when the subsidies eventually expire.

Earlier this year, a temporary option to extend Medicaid postpartum coverage from 60 days to 12 months took effect. This option, included in the American Rescue Plan Act (ARPA), is part of a broader federal and state effort to address racial disparities and improve maternal and infant health outcomes. Medicaid is a key source of coverage for low-income women in the United States and covers more than four in ten births nationally. Research has documented the importance of having continuous Medicaid coverage following pregnancy to ensure access to needed care during the postpartum period, such as follow up on pregnancy complications, management of chronic health and mental health conditions, and access to family planning services. There has been, however, a history of considerable churning off the program in the postpartum period, especially among women who live in states that have not expanded Medicaid eligibility under the Affordable Care Act (ACA). KFF research has found four in ten pregnant people are disenrolled from Medicaid coverage after giving birth and if all states had adopted the postpartum extension in 2018, over 610,000 individuals who were disenrolled during the postpartum year would have been able to retain coverage.

The Supreme Court decision overturning Roe v. Wade has also refocused attention on the importance of coverage for pregnancy and postpartum care along with other maternal and child health programs. This policy watch provides an update on the status of state adoption and implementation of the Medicaid 12-month postpartum coverage extension option as states wrap up their 2022 legislative sessions.

Prior to the ARPA option, postpartum coverage was limited to 60 days. Under federal law, states must cover pregnant individuals with incomes up to at least 138% of the federal poverty level (FPL), although many states have set higher income eligibility levels, and they must extend coverage for 60-days postpartum. Following the 60-day postpartum period, in states that have adopted the Affordable Care Act (ACA)’s Medicaid expansion, individuals with incomes below 138% FPL may continue to be eligible for Medicaid coverage. Those with income above the federal poverty level may qualify for subsidized coverage through the ACA marketplace plans; however, individuals in the remaining 12 non-expansion states may become uninsured because their income is too high to qualify for Medicaid as a parent but too low to qualify for subsidized Marketplace plans. This group falls into what is called the “Medicaid coverage gap.” For example, in Mississippi, which has not sought a postpartum coverage extension nor the ACA’s Medicaid expansion, the Medicaid eligibility level for parents is 25% FPL, which is approximately $5,758/year for a family of three.

Two-thirds of states (34 including DC) have extended or have plans to extend Medicaid postpartum coverage to 12 months. Recent state actions related to 12-month postpartum coverage include the following:

• 15 states (CA, CT, DC, KY, KS, LA, MA, ME, MI, MN, NM, OR, TN, SC, & WA) received state plan amendment (SPA) approvals ;
• 4 states (MD, NC, OH, and PA) announced that coverage extension has taken effect, although CMS has not yet approved the SPAs in these states;
• 11 states (AL, AZ, CO, DE, GA, HI, IN, NY, RI, VT, & WV) are planning to implement;
• 4 states (FL, IL, NJ, VA) received Section 1115 waiver approvals.

Although states can now implement this coverage extension, postpartum coverage has been continuous during the COVID-19 public health emergency as Medicaid disenrollments have been suspended across the country in exchange for enhanced federal matching dollars. Once the public health emergency is lifted, however, this coverage will no longer be available.

Two states are seeking limited postpartum coverage extensions. Wisconsin submitted a Section 1115 waiver proposal that would extend coverage from 60 days to 90 days and Texas submitted a waiver proposal that would extend coverage to six months, with the additional four months of coverage limited to individuals who “deliver or involuntarily miscarry” only. CMS has not issued a decision on either proposal. Missouri had received CMS approval for a limited 12-month extension to postpartum individuals with substance use disorders, but the state has paused implementation of this coverage extension.

Among the 17 states not taking up the full postpartum extension, a number have not adopted the ACA Medicaid expansion and/or have banned abortion. Of these states, five (MS, SD, TX, WI, WY) have also not adopted the Medicaid expansion. After the PHE is lifted, postpartum enrollees in these states would be at particularly high risk for losing coverage just two months after their pregnancy ends. Additionally, 11 of the 17 states (AR, ID, MS, MO, ND, OK, SD, TX, UT, WI, WY) have banned abortion or have abortion bans that may soon take effect. While extending Medicaid coverage to postpartum parents is not a replacement for abortion access, a pathway to stable coverage could ensure access to care to those who could be affected by the abortion bans and improve access to care during a time of medical vulnerability for many.

To track updated state-by-state activity on Medicaid postpartum coverage, please visit our Medicaid Postpartum Coverage Extension Tracker.

Children are now preparing to head back to school for the third time since the onset of the COVID-19 pandemic. Schools are expected to return in-person this fall, with most experts now agreeing the benefits of in-person learning outweigh the risks of contracting COVID-19 for children. Though children are less likely than adults to develop severe illness, the risk of contracting COVID-19 remains, with some children developing symptoms of long COVID following diagnosis. COVID-19 vaccines provide protection, and all children older than 6 months are now eligible to be vaccinated. However, vaccination rates have stalled and remain low for younger children. At this time, only a few states have vaccine mandates for school staff or students, and no states have school mask mandates, though practices can vary by school district. Emerging COVID-19 variants, like the Omicron subvariant BA.5 that has recently caused a surge in cases, may pose new risks to children and create challenges for the back-to-school season.

Children may also continue to face challenges due to the ongoing health, economic, and social consequences of the pandemic. Children have been uniquely impacted by the pandemic, having experienced this crisis during important periods of physical, social, and emotional development, with some experiencing the loss of loved ones. While many children have gained health coverage due to federal policies passed during the pandemic, public health measures to reduce the spread of the disease also led to disruptions or changes in service utilization and increased mental health challenges for children.

This brief examines how the COVID-19 pandemic continues to affect children’s physical and mental health, considers what the findings mean for the upcoming back-to-school season, and explores recent policy responses. A companion KFF brief explores economic effects of the pandemic and recent rising costs on households with children. We find households with children have been particularly hard hit by loss of income and food and housing insecurity, which all affect children’s health and well-being.

Children’s Health Care Coverage and Utilization

Despite job losses that threatened employer-sponsored insurance coverage early in the pandemic, uninsured rates have declined likely due to federal policies passed during in the pandemic and the safety net Medicaid and CHIP provided. Following growth in the children’s uninsured rate from 2017 to 2019, data from the National Health Interview Survey (NHIS) show that the children’s uninsured rate held steady from 2019 to 2020 and then fell from 5.1% in 2020 to 4.1% in 2021. Just released quarterly NHIS data show the children’s uninsured rate was 3.7% in the first quarter of 2022, which was below the rate in the first quarter of 2021 (4.6%) but a slight uptick from the fourth quarter of 2021 (3.5%), though none of these differences are statistically significant. Administrative data show that children’s enrollment in Medicaid and CHIP increased by 5.2 million enrollees, or 14.7%, between February 2020 and April 2022 (Figure 1). Provisions in the Families First Coronavirus Response Act (FFCRA) require states to provide continuous coverage for Medicaid enrollees until the end of the month in which the public health emergency (PHE) ends in order to receive enhanced federal funding.

Children have missed or delayed preventive care during the pandemic, with a third of adults still reporting one or more children missed or delayed a preventative check-up in the past 12 months (Figure 2). However, the share missing or delaying care is slowly declining, with the share from April 27 – May 9, 2022 (33%) down 3% from almost a year earlier (July 21 – August 2, 2021) according to KFF analysis of the Household Pulse Survey. Adults in households with income less than $25,000 were significantly more likely to have a child that missed, delayed, or skipped a preventive appointment in the past 12 months compared to households with income over $50,000. These data are in line with findings from another study that found households reporting financial hardship were significantly more likely to report missing or delaying children’s preventive visits compared to those not reporting hardships. Hispanic households and households of other racial/ethnic groups were also significantly more likely to have a child that missed, delayed, or skipped a preventive appointment in the past 12 months compared to White households (based on race of the adult respondent).

Telehealth helped to provide access to care, but children with special health care needs and those in rural areas continued to face barriers. Overall, telehealth utilization soared early in the pandemic, but has since declined and has not offset the decreases in service utilization overall. While preventative care rates have increased since early in the pandemic, many children likely still need to catch up on missed routine medical care. One study found almost a quarter of parents reported not catching-up after missing a routine medical visit during the first year of the pandemic. The pandemic may have also exacerbated existing challenges accessing needed care and services for children with special health care needs, and low-income patients or patients in rural areas may have experienced barriers to accessing health care via telehealth.

The pandemic has also led to declines in children’s routine vaccinations, blood lead screenings, and vision screenings. The CDC reported vaccination coverage of all state-required vaccines declined by 1% in the 2020-2021 school year compared to the previous year, and some public health leaders note COVID-19 vaccine hesitancy may be spilling over to routine child immunizations. The CDC also reported 34% fewer U.S. children had blood lead level testing from January-May 2020 compared to the same period in 2019. Further, data suggest declines in lead screenings during the pandemic may have exacerbated underlying gaps and disparities in early identification and intervention for lower-income households and children of color. Additionally, many children rely on in-school vision screenings to identity vision impairments, and some children went without vision checks while schools managed COVID-19 and turned to remote learning. These screenings are important for children in order to identify problems early; without treatment some conditions can worsen or lead to more serious health complications.

The pandemic has also led to difficulty accessing and disruptions in dental care. Data from the National Survey of Children’s Health (NSCH) show the share of children reporting seeing a dentist or other oral health provider or having a preventive dental visit in the past 12 months declined from 2019 to 2020, the first year of the pandemic (Figure 3). The share of children reporting their teeth are in excellent or very good conditions also declined from 2019 (80%) to 2020 (77%); the share of children reporting no oral health problems also declined but the change was not statistically significant.

Recently released preliminary data for Medicaid/CHIP beneficiaries under age 19 shows steep declines in service utilization early in the pandemic, with utilization then rebounding to a varying degree depending on the service type. Child screening services have rebounded to pre-PHE levels while blood lead screenings and dental services rates remain below per-PHE levels. Telehealth utilization mirrors national trends, increasing rapidly in April 2020 and then beginning to decline in 2021. When comparing the PHE period (March 2020 – January 2022) to the pre-PHE period (January 2018 – February 2020) overall, the data show child screening services and vaccination rates declined by 5% (Figure 4). Blood lead screening services and dental services saw larger declines when comparing the PHE period to before the PHE, declining by 12% and 18% respectively among Medicaid/CHIP children.

Children’s Mental Health Challenges

Children’s mental health challenges were on the rise even before the onset of the COVID-19 pandemic. A recent KFF analysis found the share of adolescents experiencing anxiety and/or depression has increased by one-third from 2016 (12%) to 2020 (16%), although rates in 2020 were similar to 2019.  Rates of anxiety and/or depression were more pronounced among adolescent females and White and Hispanic adolescents. A separate survey of high school students in 2021 found that lesbian, gay, or bisexual (LGB) students were more likely to report persistent feelings of sadness and hopelessness than their heterosexual peers. In the past few years, adolescents have experienced worsened emotional health, increased stress, and a lack of peer connection along with increasing rates of drug overdose deaths, self-harm, and eating disorders. Prior to the pandemic, there was also an increase in suicidal thoughts from 14% in 2009 to 19% in 2019.

The pandemic may have worsened children’s mental health or exacerbated existing mental health issues among children. The pandemic caused disruptions in routines and social isolation for children, which can be associated with anxiety and depression and can have implications for mental health later in life. A number of studies show an increase in children’s mental health needs following social isolation due to the pandemic, especially among children who experience adverse childhood experiences (ACEs). KFF analysis found the share of parents responding that adolescents were experiencing anxiety and/or depression held relatively steady from 2019 (15%) to 2020 (16%), the first year of the pandemic. However, the KFF COVID-19 Vaccine Monitor on perspectives of the pandemic at two years found six in ten parents say the pandemic has negatively affected their children’s schooling and over half saying the same about their children’s mental health. Researchers also note it is still too early to fully understand the impact of the pandemic on children’s mental health. The past two years have also seen much economic turmoil, and research has shown that as economic conditions worsen, children’s mental health is negatively impacted. Further, gun violence continues to rise and may lead to negative mental health impacts among children and adolescents. Research suggests that children and adolescents may experience negative mental health impacts, including symptoms of anxiety, in response to school shootings and gun-related deaths in their communities.

Access and utilization of mental health care may have also worsened during the pandemic. Preliminary data for Medicaid/CHIP beneficiaries under age 19 finds utilization of mental health services during the PHE declined by 23% when compared to prior to the pandemic (Figure 4); utilization of substance use disorder services declined by 24% for beneficiaries ages 15-18 for the same time period. The data show utilization of mental health services remains below pre-PHE levels and has seen the smallest improvement compared to other services utilized by Medicaid/CHIP children. Telehealth has played a significant role in providing mental health and substance use services to children early in the pandemic, but has started to decline. The pandemic may have widened existing disparities in access to mental health care for children of color and children in low-income households. NSCH data show 20% of children with mental health needs were not receiving needed care in 2020, with the lowest income children less likely to receive needed mental health services when compared to higher income groups (Figure 5).

Children’s Health and COVID-19

While less likely than adults to develop severe illness, children can contract and spread COVID-19 and children with underlying health conditions are at an increased risk of developing severe illness. Data through July 28, 2022 show there have been over 14 million child COVID-19 cases, accounting for 19% of all cases. Among Medicaid/CHIP enrollees under age 19, 6.4% have received a COVID-19 diagnosis through January 2022. Pediatric hospitalizations peaked during the Omicron surge in January 2022, and children under age 5, who were not yet eligible for vaccination, were hospitalized for COVID-19 at five times the rate during the Delta surge.

Some children who tested positive for the virus are now facing long COVID. A recent meta-analysis found 25% of children and adolescents had ongoing symptoms following COVID-19 infection, and finds the most common symptoms for children were fatigue, shortness of breath, and headaches, with other long COVID symptoms including cognitive difficulties, loss of smell, sore throat, and sore eyes. Another report found a larger share of children with a confirmed COVID-19 case experienced a new or recurring mental health diagnosis compared to children who did not have a confirmed COVID-19 case. However, researchers have noted it can be difficult to distinguish long COVID symptoms to general pandemic-associated symptoms. In addition, a small share of children are experiencing multisystem inflammatory syndrome in children (MIS-C), a serious condition associated with COVID-19 that has impacted almost 9,000 children. A lot of unknowns still surround long COVID in children; it is unclear how long symptoms will last and what impact they will have on children’s long-term health.

COVID-19 vaccines were recently authorized for children between the ages of 6 months and 5 years, making all children 6 months and older eligible to be vaccinated against COVID-19. Vaccination has already peaked for children under the age of 5, and is far below where 5-11 year-olds were at the same point in their eligibility. As of July 20, approximately 544,000 children under the age of 5 (or approximately 2.8%) had received at least one COVID-19 vaccine dose. Vaccinations for children ages 5-11 have stalled, with just 30.3% have been fully vaccinated as of July 27 compared to 60.2% of those ages 12-17.  Schools have been important sites for providing access as well as information to help expand vaccination take-up among children, though children under 5 are not yet enrolled in school, limiting this option for younger kids. A recent KFF survey finds most parents of young children newly eligible for a COVID-19 vaccine are reluctant to get them vaccinated, including 43% who say they will “definitely not” do so.

Some children have experienced COVID-19 through the loss of one or more family members due to the virus. A study estimates that, as of June 2022, over 200,000 children in the US have lost one or both parents to COVID-19. Another study found children of color were more likely to experience the loss of a parent or grandparent caregiver when compared to non-Hispanic White children. Losing a parent can have long term impacts on a child’s health, increasing their risk of substance abuse, mental health challenges, poor educational outcomes, and early death. There have been over 1 million COVID-19 deaths in the US, and estimates indicate a 17.5% to 20% increase in bereaved children due to COVID-19, indicating an increased number of grieving children who may need additional supports as they head back to school.

Looking Ahead

Children will be back in the classroom this fall but may continue to face health risks due to their or their teacher’s vaccination status and increasing transmission due to COVID-19 variants. New, more transmissible COVID-19 variants continue to emerge, with the most recent Omicron subvariant BA.5 driving a new wave of infections and reinfections among those who have already had COVID-19. This could lead to challenges for the back-to-school season, especially among young children whose vaccination rates have stalled.

Schools, parents, and children will likely continue to catch up on missed services and loss of instructional time in the upcoming school year. Schools are likely still working to address the loss of instructional time and drops in student achievement due to pandemic-related school disruptions. Further, many children with special education plans experienced missed or delayed services and loss of instructional time during the pandemic. Students with special education plans may be entitled to compensatory services to make up for lost skills due to pandemic related service disruptions, and some children, such as those with disabilities related to long COVID, may be newly eligible for special education services.

To address worsening mental health and barriers to care for children, several measures have been taken or proposed at the state and federal level. Many states have recently enacted legislation to strengthen school based mental health systems, including initiatives such as from hiring more school-based providers to allowing students excused absences for mental health reasons. In July 2022, 988 – a federally mandated crisis number – launched, providing a single three-digit number for individuals in need to access local and state funded crisis centers, and the Biden Administration released a strategy to address the national mental health crisis in May 2022, building on prior actions. Most recently, in response to gun violence, the Bipartisan Safer Communities Act was signed into law and allocates funds towards mental health, including trauma care for school children.

The unwinding of the PHE and expiring federal relief may have implications for children’s health coverage and access to care. The American Rescue Plan Act (ARPA) extended eligibility to ACA health insurance subsides for people with incomes over 400% of poverty and increased the amount of assistance for people with lower incomes. However, these subsidies are set to expire at the end of this year without further action from Congress, which would increase premium payments for 13 million Marketplace enrollees. In addition, provisions in the FFCRA providing continuous coverage for Medicaid enrollees will expire with the end of the PHE. Millions of people, including children, could lose coverage when the continuous enrollment requirement ends if they are no longer eligible or face administrative barriers during the process despite remaining eligible. There will likely be variation across states in how many people are able to maintain Medicaid coverage, transition to other coverage, or become uninsured. Lastly, there have also been several policies passed throughout the pandemic to provide financial relief for families with children, but some benefits, like the expanded Child Tax Credit, have expired and the cost of household items is rising, increasing food insecurity and reducing the utility of benefits like SNAP.

American families have reported struggling throughout the COVID pandemic on a variety of economic indicators. Recent trends in inflation reported by the Bureau of Labor Statistics in June threaten to further reduce the buying power of American families and to exacerbate existing financial hardship and disparities. Prior to this period of inflation levels not seen for decades, many families had already been struggling to pay their normal household expenses, pay for rent or mortgage payments, and to obtain sufficient food to feed their family. These challenges have consistently been more acute for families with a child in the household compared to households without children, and especially so for lower-income families.

Federal policymakers have taken several actions to mitigate the economic impact of the pandemic on families and children by providing state fiscal relief, increased nutrition assistance, Medicaid funding, and the Child Tax Credit (CTC) and Earned Income Tax Credit (EITC); however, some of this assistance has or will expire. This brief examines hardship across three metrics—difficulty paying for normal household expenses, food sufficiency, and uncertainty in paying for rent or mortgage payments for households with children and by income.

How does household income affect children’s health and well-being?

Household income has been historically linked to children’s health and education outcomes. Even before the pandemic, families with children living near or below the federal poverty line have historically had higher rates of food insufficiency, worse infant health outcomes, and worse academic achievement, than higher income peers. In 2020, 33.7% of households with children with incomes below 185% of the poverty threshold were food insecure, more than double the national average of 14.8%. Evidence also shows that household income affects children’s health as well as their cognitive and social development. A 2020 report from the U.S. Department of Education found that students considered economically disadvantaged were almost one and a half times as likely to not graduate high school within four years of entering the 9^th grade. Financial instability can also lead to stress and mental health challenges for parents that can negatively affect children’s emotional and mental health.

Economic stability is also a social determinant of health and addressing social determinants of health is important for improving health outcomes and reducing health disparities. For this reason, recent policies, like the CTC, have targeted financial relief to families with children. Addressing child poverty is associated with improved child health outcomes such as healthier birthweights, lower maternal stress, better nutrition, and lower use of drugs and alcohol. Cash transfers have been associated with improved health outcomes, and a recent study found increased brain activity in babies of low-income workers provided cash assistance.

How have households with children fared throughout the pandemic?

Households with children have consistently fared worse than households without children throughout the pandemic.  Challenges for all households peaked early in the pandemic and then improved by summer 2021; however, adults living with children have consistently reported more difficulty paying daily household expenses, providing adequate food for their family, and have been less secure in their housing payments compared to other households (Figure 1).

Improvements in measures of hardship in 2021 were likely related to improving economic conditions and several federal policies implemented during the pandemic that provided financial relief for individuals and families.  Following the onset of the pandemic, national employment indicators quickly worsened, creating one of the deepest recessions on record. While this recession was deep, it was also the shortest on record at two months.  Federal fiscal relief for individuals and families, including direct stimulus payments, expanded unemployment benefits, the Emergency Rental Assistance Program, and enhanced Supplemental Nutrition Assistance Program (SNAP) benefits as well as the availability of COVID vaccines led to improvements in employment indicators and measures of hardship in 2021.  Federal support was likely the driving force behind a decrease in overall poverty rates in 2020, and the expanded Child Tax Credit (CTC) included in the American Rescue Plan Act (ARPA) is expected to further contribute to lower rates of child poverty in 2021.  Early data show the monthly child poverty rate declined by almost 30% following the beginning of the advance payments of the CTC in July 2021. A recent report also found food insufficiency declined by 26% in households with children who received advance CTC payments. The expanded CTC applied to families previously too poor to qualify and gave families in the lowest quintile an average income boost of $4,470.

However, recent data signal measures of hardship are again on the rise, particularly for households with children. All households have reported their highest rates of difficulty paying usual household expenses and food insufficiency since the earlier in the pandemic, with households with children experiencing more challenges across measures. In latest data, food security has also increased among households with children, a trend not seen in households without children. Despite worsening rates of hardship in other metrics, the shares of both households with and without children report having no confidence in their ability to pay their rent or mortgage has remained stable in recent months.

Recent increases in hardship are likely due to rising inflation and the costs of goods as well as the expiration of the Child Tax Credit. The U.S. Bureau of Labor Statistics reported inflation accelerated to 9.1% in June 2022, with the largest contributors being gasoline, and food. In the absence of school provided low-cost and free lunches to children through the National School Lunch Program, the summer months can be a difficult time for families to meet their food needs. Recent high inflation increasing food costs can lead to increased food insecurity for children. Increased costs reduce a family’s purchasing power and limits how much benefits like SNAP can cover, which can make it more difficult to purchase food, and pay bills. The recent baby formula shortage increased the costs of formula, and some WIC recipients have reported paying out of pocket to obtain the formula they need. Further, the expanded Child Tax Credit benefits expired at the end of 2021, and a recent report found a 12% increase in food insufficiency following expiration of the advance CTC payments.

Are lower-income families with children facing disproportion levels of hardship over other households?

Overall, families with children are experiencing higher rates of economic hardship than families without children. 49% of adults with children in the household reported difficultly paying for expenses in the past week, 16% reported food insufficiency in their household, and 8% reported not having confidence in their ability to make their next month’s housing payment (Figure 2). Families with a child were significantly more likely to report difficulty paying for their usual expenses, food insufficiency and low confidence in their ability to make next month’s housing payment than those families without a child.

Among all households with children, families with an income less than $25,000 are more likely to report economic hardship than higher earning households. Among the lowest-income adults living with one or more children, 78% (roughly 7.2 million adults)¹  reported having difficulty paying their usual household expenses, 40% (roughly 3.6 million adults) reported having food insufficiency, and 19% (roughly 1.4 million adults) reported having no confidence to make next month’s housing payment (Figure 2). Despite higher earnings, over 1 in 3 adults making $50,000 and above have reported having difficulty paying their usual household expenses as well.

Looking Ahead

As financial hardships for families are rising, some fiscal relief provided to families throughout the pandemic has expired or is expected to expire soon. The expanded Child Tax Credit expired at the end of 2021. When the Public Health Emergency (PHE) expires, several expanded SNAP benefits will also expire. Recent inflationary pressures may magnify the effects of the expiring federal assistance as well as other economic and health issues stemming from COVID-19 as children transition back to school in the fall.

1. KFF analysis of data from the Census Household PULSE Survey from June 29–July 11 (Difficulty paying usual household expenses, and food insufficiency), and from April 27 – May 9, 2022 (No Confidence in paying next months rent/mortgage payment). 95% confidence intervals for these estimates are as follows: “Difficulty paying usual household expenses” (6,423,727–7,919,960), “Food insufficiency” (3,113,361–4,149,963), and “No confidence in paying next month’s rent/mortgage payment” (1,083,440–1,772,036) ↩︎