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) ↩︎

Following the Supreme Court’s decision to end the constitutional right to an abortion, most voters (55%) now say access to abortion is “very important” to their vote in November’s midterm elections, up 9 percentage points since February prior to the decision, a new KFF Health Tracking Poll finds.

This heightened interest is greatest among key voter groups who largely want to guarantee access to abortion, including Democratic voters (77% now say abortion access is very important, up from 50% in February), Democratic women voters (82%, up from 55%), and women voters under 50 years old (73%, up from 59%).

At the same time, fewer Republican women voters say access to abortion is very important to their vote now than in February (44%, down from 60%), perhaps a sign that the Supreme Court’s recent decision made the issue less salient for a group who largely want to restrict abortion.

While abortion has become a more salient issue for certain voting groups, and while economic issues dominate, the poll suggests that the Supreme Court decision’s impact on the 2022 midterm elections could have an impact at the margins.

“Lower-turnout midterm elections can be a game of inches, and abortion could make a difference, especially if gas prices continue to fall,” KFF President and CEO Drew Altman said. “It’s motivating a lot of younger women to vote, and most Democrats, half of independents and even some Republicans plan to vote for candidates who support abortion access.”

For example, just over half of voters (54%) say the decision in the Dobbs v. Jackson Women’s Health Center overturning Roe v. Wade has made them “more likely” to consider a candidate’s position on abortion when deciding whom to vote for, while few (3%) say it has made them “less likely” to do so.

This includes large majorities of Democratic voters (72%), Democratic women voters (72%), and women voters under 50 (64%) who say the overturn of Roe has made them “more likely” to consider a candidate’s position on abortion.

In addition, when asked about the decision’s impact on their motivation to vote, 43% of all voters say it has made them “more motivated,” a slight uptick compared to a similar question in May (37%) before the Court’s ruling but after the draft opinion leaked. This includes nearly two thirds of Democrats (64%), four in 10 independents (41%), and a fifth of Republicans (20%). The vast majority (82%) of those who are more motivated say they plan to vote for candidates who will protect abortion access.

Some groups saw a larger boost in motivation, including reproductive-age women. Now 61% of this group says the decision makes them more motivated to vote, up 19 percentage points from May (42%). Again, the vast majority (88%) of the motivated group plans to vote for candidates who will protect access.

While some of these findings suggest abortion could play a larger role in this year’s midterms, voters overall continue to prioritize inflation, including gas prices, as their top voting issue.

Three-quarters (74%) of voters say inflation, including rising gas prices, will be “very important” to their vote. Abortion access (55%) ranks in a second tier with gun violence (57%) and health care costs, including prescription drug costs (55%).

One reason inflation and gas prices may sit atop voters’ priorities is because most people are worried about their ability to afford routine household expenses.

This includes three quarters (76%) who say they are at least somewhat worried about paying for gasoline or other transportation costs. Somewhat smaller majorities say they worry about affording unexpected medical bills (64%), their monthly utilities like electricity and heat (62%), and food (61%).

Post-Roe, Most Adults Want Their State to Guarantee Abortion Access Rather than Ban It

The Supreme Court’s decision in Dobbs allows states to make laws about abortion in their state. The new survey finds that most (61%) of the public says they want their state to guarantee access to abortion, while a quarter (25%) want their states to ban it.

Those who favor state action to protect abortion access includes large majorities of Democrats (83%), independents (65%), and women of reproductive age (68%). In contrast, just over half (54%) of Republicans want their states to ban abortion.

There are 17 states that already have laws on the books that ban abortion, either from before Roe or from more recent “trigger” laws anticipating Roe’s end. About half (51%) of those living in states that have or are anticipated to ban abortion soon say they want their states to protect access to abortion, compared to a third (32%) that want their state to ban it.

About two thirds (68%) of women under 50 want their state to guarantee access to abortion. This includes large majorities of Democratic (82%) and independent (74%) women in that age group, though about half (48%) of Republican women in that age range want their states to ban abortion.

Other findings include:

• Two thirds (65%) of the public disapprove of the Supreme Court decision overturning Roe. Most Democrats (90%) and independents (72%) disapprove of the decision, while most Republicans (71%) approve of it.
• Most (83%) Democratic voters say they plan on voting for a candidate who wants to protect access to abortion, as do a narrower majority (56%) of independent voters. Half of Republicans voters (51%) plan on voting for a candidate who wants to limit abortion access, though one in five (20%) plan to vote for a candidate who wants to protect access.
• While most Republican women share their party’s views on abortion, a third (34%) disapprove of the Court’s decision overturning Roe. A quarter (25%) of Republican women voters say they plan to vote for a candidate who wants to protect access to abortion.
• In the 17 states that have abortion bans on the books, nearly three quarters (73%) of residents are aware that abortion has or will soon be banned. In 16 states and the District of Columbia that have laws protecting the right to abortion, a similar share (72%) is aware that abortion will remain legal in their states.

Designed and analyzed by public opinion researchers at KFF, the Health Tracking Poll was conducted from July 7-17, 2022, online and by telephone among a nationally representative sample of 1,847 U.S. adults in English and Spanish. The margin of sampling error is plus or minus 4 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher.

Long COVID has been described as our “next national health disaster” and the “pandemic after the pandemic,” but we know little about how many people are affected, how long it will last for those affected, and how it could change employment and health coverage landscapes. This policy watch reviews what we know and outlines key questions to watch for regarding employment and coverage outcomes. We continue to follow the research on who is most at risk of long COVID and whether there are interventions that can reduce its incidence, length, or severity. The numbers are already daunting and infections continue to rise. The newest subvariant—BA.5— readily infects the vaccinated and people with prior immunity. Vaccines and prior immunity protect against severe illness and death, but it is unclear whether they protect against long COVID. One study of the VA health system found that the risks of long COVID increased with each subsequent reinfection.

Long COVID involves a range of potentially disabling symptoms and may affect 10 to 33 million working-age adults in the United States (Figure 1). Long COVID is not a single condition but rather “a wide range of new, returning, or ongoing health problems that people experience after first being infected with the virus that causes COVID-19,” according to the CDC. Patients report a wide range of physical and mental health conditions including malaise, fatigue, breathing challenges, cardiovascular abnormalities, migraines, and mental health impairments. There is no standard presentation of or treatment for long COVID. It is a new phenomenon and the ICD-10 code to identify medical claims only became available in October 2021. Also unknown is how long people with long COVID will remain ill, although one study reported that 29 percent of long COVID patients had self-reported symptoms for more than one year. The prevalence of long COVID is equally uncertain with studies finding that the percentage of working age adults with COVID who develop long COVID could be 10 percent, 20 percent, or 33 percent. If we conservatively assume 100 million working age adults have been infected, that implies 10 to 33 million may have long COVID.

Preliminary evidence suggests there may be significant implications for employment: Surveys show that among adults with long COVID who worked prior to infection, over half are out of work or working fewer hours (Figure 2). Many conditions associated with long COVID—such as malaise, fatigue, or the inability to concentrate—limit people’s ability to work, even if they have jobs that allow for remote work and other accommodations. Two surveys of people with long COVID who had worked prior to infection showed that between 22% and 27% of those workers were out of work after getting long COVID. In comparison, among all working-age adults in 2019, only 7% were out of work. Given the sheer number of working age adults with long COVID, the employment implications may be profound and are likely to affect more people over time. One study estimates that long COVID already accounts for 15 percent of unfilled jobs.

It is too early to have comprehensive data or a clear picture of employment outcomes but there are reports that claims associated with long COVID are rising for disability insurance, workers compensation, and group health insurance. Those higher claims could increase costs for insurers and eventually, employers. It is unclear how long-term these challenges will be and whether health insurance spending will rise because of long COVID. It is also unclear how employment consequences will be spread across industries, but some industries are likely to be disproportionately affected—particularly those with higher rates of initial infection, such as health care.

There may be significant changes in health coverage associated with long COVID. Over 60% of working-age adults have their health insurance coverage through an employer. Changes in employment would therefore have significant effects on people’s sources of health insurance. People who are no longer able to work could eventually lose their existing coverage and would also experience loss of income. Some could newly qualify for help paying for private health insurance through the ACA marketplaces. Others could newly qualify for Medicaid – though eligibility is more limited in the dozen states that have not expanded the program under the ACA. Those with high medical spending could qualify for Medicaid through medically needy programs.

An important question for the future is whether federal disability programs will count long COVID as a disability. The Office of Civil Rights within the U.S. Department of Health and Human Services determined that long COVID can be a disability under the Americans with Disabilities Act if an individual assessment determines that it substantially limits one or more major life activities. Despite the recognition that long COVID can be a disability, to qualify for federal programs, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI), applicants must be unable to work and have health conditions that last for at least one year or result in death. At this point, it is unclear how many people with long COVID will qualify for disability benefits under this definition. If people with long COVID quality for federal disability programs, more people will have publicly funded health insurance through Medicare and Medicaid. People who are eligible for SSDI become eligible for Medicare after a 2-year waiting period and people who are eligible for SSI are generally eligible for Medicaid. If people with long COVID are unable to work, federal disability programs could play a key role helping those patients access the health care they need to recover.

The recent monkeypox outbreak continues to surge in the U.S., as it does in many countries across the globe. Confirmed cases have climbed from just 40 on June 8, 2022 to 4,639 on July 27, 2022, distributed across almost all states. There is a significant risk that the current outbreak could become endemic in the U.S., if not further contained. One of the best tools available to help mitigate the outbreak is vaccination. However, there is a limited supply of vaccines and widespread reports that demand is outstripping supply, particularly in some jurisdictions.

Among the many factors that may be influencing supply at the local level is whether jurisdictions are requesting the vaccines allocated to them. Here, we explore jurisdictional request rates for JYNNEOS, the preferred monkeypox vaccine, based on publicly available data in all 50 states, Washington D.C., and 5 cities (allocations are also made to territories and tribal entities not described in this analysis) as of July 22, 2022. (Data as of July 22, 2022 are available here; current federal data are available here.) Overall, we find that while most jurisdictions have requested their full supply, some are well below that mark, raising questions about how quickly their at-risk populations can get protected.

There are currently two vaccines that can be used in the U.S. to prevent monkeypox: JYNNEOS and ACAM2000. JYNNEOS is FDA-approved for both monkeypox and smallpox, while ACAM2000 is approved for smallpox but has been granted an expanded access Investigational New Drug (EA-IND) protocol to allow its use for monkeypox. While both vaccines are effective, JYNNEOS is preferred because it has a lower risk profile for both the patient and provider, is less invasive to administer, and is not contraindicated for people with conditions associated with being immunocompromised, including people with HIV, who are pregnant, or have other select conditions, as is the case with ACAM2000. As such, JYNNEOS is being prioritized in the U.S. roll-out.

The federal government uses an evolving algorithm to determine allocation levels to jurisdictions based on current and projected monkeypox case burden in a jurisdiction and the size of the jurisdiction’s at-risk population, defined as men who have sex with men with HIV or who have an indication for HIV pre-exposure prophylaxis (PrEP). Jurisdictions must then request vaccine supply from the Centers for Disease Control and Prevention (CDC).

As of July 22, 2022, almost all (97%) of the allocated JYNNEOS vaccine supply has been requested by jurisdictions across the country. However, this varies significantly, and while most jurisdictions have requested their full allocation, a subset have requested well below:

• The request rate – the number of vaccine doses requested as a share of the jurisdiction’s allocation — ranges from a low of just 3% in Arkansas to a high of 115% in Maine.
• The majority of jurisdictions (37) have requested their full allocation of vaccine. This includes 11 that have requested 100% and 26 that have requested even more than their allocated amount (See Figure 1).
• The remaining 19 jurisdictions have requested less than their share, including 10 that have requested 50% or less (WA, MO, KS, GA, NV, MT, SD, OK, KY, and AR).
• Of the 10 that have requested 50% or less, some have relatively small numbers of confirmed cases, or no confirmed cases at all, and smaller at-risk populations. However, this is not the case for all. For example, Georgia has 312 cases and Washington state has 103 cases (both as of  July 27, 2022) and they have large or moderate size populations of men who have sex with men with HIV (with Georgia ranking 5^th among all states and Washington ranking 18^th), but they have requested 43% and 50% of their allocated doses, respectively. This may be temporary or an issue of timing – a recent media report notes that Georgia plans to request their full allocation soon.

Overall, there are not enough vaccine doses to meet demand right now and most jurisdictions are maxing out or exceeding their allocation and, in some cases, still unable to meet demand. However, this is not the case everywhere and jurisdictions likely have different reasons for not requesting the full allocation. In some cases, states with no or low reported cases may not see an immediate need for the full vaccine allocation. In others there may be separate challenges at play. In the case of Georgia for example, the state indicated that its initially low request rate was due to concerns around storage and wanting more time to prepare and connect with community partners. While in some cases this may reflect an initial timing and/or preparedness issue, it is important to note that speed still plays a key role in curbing a growing outbreak.

Jurisdictions were notified of their 3rd round of vaccine allocation on July 28, 2022, which means more supply but also that they will likely now be grappling again with how much to request to respond to local need. Beyond the number of doses each jurisdiction accesses, there are other factors that could enhance or complicate vaccine uptake, including where vaccine access points are located, which community partners are included, how public officials educate those at risk about vaccination, the impact of stigma, and vaccine communication strategies, among others. Ultimately, and as we have written elsewhere, variation in jurisdictional decisions about how to address the monkeypox outbreak, including their vaccination strategy, will likely have an impact on local and national success in curbing it.

The Senate Committee on Appropriations released its FY 2023 State, Foreign Operations, and Related Programs (SFOPs) (links to bill and report) and Labor, Health and Human Services, Education, and Related Agencies (Labor HHS) (links to bill and report) appropriations bills and accompanying reports on July 28, 2022. The SFOPs bill includes funding for U.S. global health programs at the State Department and the U.S. Agency for International Development (USAID), while the Labor HHS bill includes funding for global health programs at the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). Funding provided to the State Department and USAID under the SFOPs bill and through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totals $10.5 billion, an increase of $680 million above the FY 2022 enacted level, but $67 million below the FY 2023 request and $467 million below the FY 2023 House level. The bill provides higher levels of funding for almost all program areas compared to the FY 2022 enacted level, with the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and family planning and reproductive health (FP/RH) receiving the largest increases. The bill also codifies the prohibition of the Mexico City Policy (see KFF explainer here). In addition to regular appropriations for global health, the SFOPs bill provides $950 million in emergency global health security supplemental funding and $5 billion in emergency coronavirus response supplemental funding. Total global health funding at CDC and NIH through the Labor HHS bill is not yet known, as funding for some programs at NIH is determined at the agency level rather than specified by Congress in annual appropriations bills. Of the known amounts, the Senate bill totals $850 million, which is $117 million above the FY 2022 enacted level, $7 million above the FY 2023 request, but $7 million below FY 2023 House level. Funding for all global health programs at CDC and NIH in the Senate bill either increased or remained flat compared to the FY 2022 enacted level. See Table 1 below for additional detail on global health funding and Tables 2 and 3 for additional detail on emergency global health security and emergency coronavirus response supplemental funding (Downloadable tables here). See the KFF budget tracker for details on historical annual appropriations for global health programs.

Addressing the cost of insulin continues to be at the forefront of policy discussions around prescription drugs. Legislation has been introduced in Congress that would cap monthly copayments for insulin products at $35 for people with Medicare and private insurance, require the federal government to negotiate insulin prices, and encourage insulin manufacturers to lower list prices. To inform discussions about these proposals, this analysis updates prior work from KFF on out-of-pocket spending on insulin products by Medicare beneficiaries enrolled in Part D drug plans, along with state-level use and spending data, based on prescription drug event claims data through 2020 from the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse. Available claims data predate the 2021 introduction of the CMS Part D Senior Savings Model in which enhanced Part D drug plans charge a monthly copayment of no more than $35 for selected insulin products. Therefore, this analysis does not reflect any potential cost savings for Part D enrollees who have enrolled in these plans since 2021.

In the aggregate, Part D enrollees spent $1 billion out of pocket on insulin in 2020, more than four times the amount spent in 2007

Aggregate out-of-pocket spending by people with Medicare Part D for insulin products quadrupled between 2007 to 2020, increasing from $236 million to $1.03 billion (Figure 1). The number of Medicare Part D enrollees using insulin doubled over these years, from 1.6 million to 3.3 million beneficiaries, which indicates that the increase in aggregate out-of-pocket spending was not solely a function of more Medicare beneficiaries using insulin.

Average out-of-pocket spending per insulin prescription was $54 in 2020 – over 50% more than the proposed $35 monthly copay cap for insulin – but spending on many insulin products was higher

Among Medicare Part D insulin users who do not receive low-income subsidies, average out-of-pocket costs per prescription across all insulin products was $54 in 2020 – over 50% more than the proposed $35 monthly copay cap for insulin. The $54 per-prescription average in 2020 is an increase of 39% since 2007.

Among all insulin products available in 2020, out-of-pocket spending per prescription by non-LIS Part D enrollees ranged from $16 for Humulin N, an intermediate-acting insulin used by 74,000 non-LIS enrollees in 2020, to $116 for Humulin R U-500, a short-acting concentrated insulin used by 3,600 non-LIS enrollees in 2020 (Figure 2). Some of the more commonly used insulin products with above-average per prescription costs in 2020 include Novolog Mix 70-30 Flexpen ($77 per prescription; used by 32,900 non-LIS enrollees); Tresiba Flextouch U-200 ($70 per prescription; used by 93,700 non-LIS enrollees); and Levemir ($67 per prescription; used by 43,000 non-LIS enrollees).

Among insulin users, Part D enrollees without low-income subsidies spent $572 per person for insulin in 2020, on average, but a small share of insulin users spent considerably more

Among insulin users without Part D low-income subsidies (LIS), average annual out-of-pocket spending on insulin per user increased by 76% between 2007 and 2020, from $324 to $572 (Figure 3; see Table 1 for 2020 insulin use and spending by state). Average annual growth in out-of-pocket costs between 2007 and 2020 was 4.5%, which exceeded the 1.7% average annual rate of growth in inflation over these same years.

Some Part D insulin users spent considerably more than the average in 2020. For example, 10% of non-LIS insulin users spent more than $1,300 on insulin in 2020 and 1% spent more than $2,300 (Figure 4). Higher-than-average out-of-pocket spending is due to a greater number of prescription fills for insulin products and higher out-of-pocket costs per insulin prescription. In other words, taking more than one insulin product and taking more expensive formulations leads to higher out-of-pocket costs.

If insulin copays were capped at $35, Part D enrollees would save 35% on average, based on spending of $54 per prescription in 2020

Policymakers have introduced proposals to cap monthly copayments for insulin products, building on the Part D insulin model. If a $35 monthly copay cap for all insulin products had been in place in 2020, Part D enrollees without low-income subsidies would have saved $19 per insulin prescription, on average—a reduction of 35% based on average out-of-pocket costs of $54 per insulin prescription in 2020.

Under the current Part D insulin model, participating plans are not required to cover all insulin products at the $35 monthly copayment amount, just one of each dosage form (vial, pen) and insulin type (rapid-acting, short-acting, intermediate-acting, and long-acting). Absent a requirement to cover all insulin products at no more than a $35 copay, insulin users might need to switch from one insulin product to another to save on their out-of-pocket costs, or switch to a plan that covers their insulin product at the $35 copayment.

With the Omicron wave of COVID-19 sweeping the country, we previously calculated the number of people who were not up to date with vaccination in vulnerable areas as of June 2, 2022. Specifically, we looked at counties classified by the Centers for Disease Control and Prevention (CDC) has having “medium” or “high” COVID-19 community levels, signifying not only that new COVID cases were on the rise but also strains on hospital capacity. Since then, the BA.5 Omicron variant, which appears to be even more contagious and is able to evade prior immunity, has become dominant, driving up cases and hospitalizations even further.

Now, less than two months later, the share of the population living in medium or high community level counties and the number of people in those counties who are not up to date on vaccination have grown significantly; in addition, most who are not up to date are now living in counties with high community levels. We provide an update here, as of July 21, 2022.

Findings

• The share of the U.S. population living in counties with medium or high COVID-19 community levels is 87% or 283 million people. This is up from 55% of the population (180 million people) in early June. Also, in contrast to early June, most people are living in high community level counties (61% of the total population now compared to 21% in early June).
• The number of people not up to date on vaccination in vulnerable counties has jumped to 198 million, up from 120 million. This represents a 65% increase since June 2. Most of these individuals (139 million) live in counties with high community levels, representing an increase from just 46 million people in such counties in early June. The share of those not up to date on vaccination living in high level counties has also grown, from 20% in early June to 70% now.

• Of the 198 million not up to date on vaccination in medium and high community level counties:
  • 73 million are unvaccinated, including 50.4 million living in counties with high COVID-19 community levels (up from 14 million in high level counties in early June).
  • 29.8 million are partially vaccinated, including 20.9 million who are in high level counties (up from 8 million).
  • 95.4 million are vaccinated but not yet boosted, including 67.7 million in high level counties (up from 25 million).

Most Americans are not up to date with their COVID-19 vaccines. As of July 21, 2022, 227.8 million Americans (70%) were unvaccinated, had not completed their primary series, or had not gotten a booster dose. In each state, at least half the population is not up to date on COVID-19 vaccines. In Alabama, North Carolina, and Virginia, over 80% of people are not yet up to date on COVID-19 vaccines.

Implications

In just a short time, with the spread of the latest COVID-19 Omicron variant, the number of people in the U.S. who are particularly vulnerable to the impacts of COVID-19, because they are not up to date on vaccination and live in vulnerable counties, has grown considerably, rising from 120 million in early June to 198 million now. Moreover, an even greater share of people now live in counties with high community levels. The most vulnerable among them – those who remain unvaccinated and live in counties with high community levels – has grown from 14 million to 50.4 million.

CDC recommends that all people mask indoors in areas that have high COVID-19 community levels, and that people living in medium-level counties mask based on their personal risk, but most jurisdictions and facilities do not require masking. These updated data illustrate how quickly the current wave is spreading and increasing risk across the country. These data underscore the significant vulnerability to COVID-19 illness that still exists at this time, more than a year since vaccines became widely available in the U.S. to most people. As such, they point to the importance of other public health measures, such as masking and testing, in addition to vaccination, in many parts of the country.