For decades, KFF polling has provided insights into national and state-level reproductive health care policy including multiple public opinion polls examining the experiences and attitudes of the general public as well as the group most impacted by such policies – women between the ages of 18 and 49. This latest KFF poll was fielded the week following the leak of a draft of the U.S. Supreme Court opinion on Dobbs v. Jackson Women’s Health Center. If the final ruling in the case resembles the leaked draft, the Court would overturn Roe v. Wade and end the constitutional right to abortion. This analysis examines the public’s attitudes and understanding of the future of reproductive health and abortion access in the U.S. and looks at the role abortion and a decision on Dobbs may play in the upcoming midterm elections this November.

Key Findings:

• Majorities of U.S. adults are aware of the leaked draft of the pending Supreme Court decision, and majorities across gender and partisanship say it is either “very likely” or “somewhat likely” the Supreme Court will be overturning Roe v. Wade this year. With this in mind, nearly two-thirds of adults do not want to see the decision overturned, and a large majority (74%) say abortion should be a personal choice and not something that is regulated by law.
• Among those who live in the 17 states¹  where abortion is certain or very likely to be banned if Roe v. Wade is overturned, majorities are aware that getting an abortion would be much harder in their state as a result of such a decision. However, partisans differ on whether this increased difficulty is a good or a bad thing, with Republicans more likely to say it would be a “good thing” that abortion would be harder to access in their state and Democrats more likely to view it as a “bad thing.”
• Looking ahead to the role this decision could play in the anticipated Republican Wave in the midterm elections this November, most voters (57%) say a Supreme Court ruling overturning Roe v. Wade would not make a difference in their motivation to vote in the upcoming midterms and some (6%) say it would make them less motivated to vote. On the other hand, nearly four in ten voters (37%) say such a decision would make them more motivated to vote, including at least half of all Democratic voters (55%) and Democratic voters in states where abortion is likely or certain to be banned if Roe is overturned (51%). Majorities of Republican voters (73%) and Republican women voters (74%) say it would not make a difference in their motivation to vote.
• While a Supreme Court ruling overturning Roe v. Wade doesn’t appear to motivate a majority of voters overall, there is a small share of voters (20%) who say they would be more motivated to vote and that they would only support a candidate who shares their view and wants to protect access to abortion. This includes nearly four in ten Democratic voters, Democratic women voters, and one-fourth of women voters ages 18-49. A smaller share of voters (4%) says they would be more motivated to vote by the Supreme Court decision, but in the opposite direction – to only support candidates who want to limit access to abortions.
• There is an age divide among voters who prefer candidates who want to protect abortion access, that crosses partisanship and gender lines, with voters under age 50, regardless of party identification and gender, more likely to prefer such candidates compared to their older counterparts. For example, while fewer than four in ten male voters ages 50 and over (37%) say they prefer a candidate who wants to protect abortion access, this rises to a majority (56%) of male voters ages 18-49. Most voters who prefer a candidate who wants to protect access to abortion say they would not vote for a candidate who disagreed with them on this issue (63%), compared to half of those who prefer a candidate who wants to limit access to abortion.
• If the Supreme Court overturns Roe v. Wade, states will set their own abortion policies without any federal constitutional standards. This poll finds there is some support for state restrictions on abortions, such as requiring women to wait 24 hours between a meeting with a health care provider and getting an abortion (67% support). However, majorities oppose other state laws, including at least three-fourths who oppose laws that would make it a crime for women to get an abortion (79%), allowing private citizens to sue people who provide or assist women in getting an abortion (80%), or making it a crime to cross state lines to obtain an abortion (80%).
• This KFF poll also finds that there are significant knowledge gaps on the prevalence and the overall safety of abortions. Additionally, a majority of adults (73%) and of women between ages 18-49 (60%) have not heard of mifepristone or medication abortion, the method in which most abortions occur in the U.S.

The Supreme Court Draft Opinion Leak

On May 2, 2022, Politico published a leaked draft opinion of the U.S. Supreme Court on Dobbs v. Jackson Women’s Health Center that would overturn the precedent set by Roe v. Wade and Planned Parenthood v. Casey, eliminating federal protections to the right to an abortion. The Supreme Court acknowledged the authenticity of the draft but stated, “it does not represent a decision by the Court or the final position of any member on the issues in the case.” If the draft opinion is indicative of the final opinion to be released later this month, the constitutional right to an abortion established by the 1973 case would be overturned and it would be again up to individual states to decide whether to restrict or uphold a right to abortion services. Unlike other cases regarding abortion rights since Roe v. Wade, the Dobbs case comes at a time when the ideological composition of the Supreme Court is conservative by a strong majority 6-3, and the case’s plaintiffs, the state of Mississippi, have asked, the Court to outright overturn Roe v. Wade.

Awareness of the Leaked Supreme Court Opinion Draft

Majorities of the U.S. public, across gender and partisanship, say they have heard at least some about the draft opinion that was leaked to the press, including more than one-third (37%) who say they have heard “a lot” about it. Notably, the group most likely to be impacted by this decision – women of reproductive age (ages 18 to 49)²  – report hearing the least about the leak, with a quarter (23%) saying they have heard “a lot” and nearly half saying they’ve heard “little” (24%) or “none at all” (23%).

There is some confusion among the public about what the leaked draft of the Supreme Court opinion portends for the current and future state of abortion access in the country. The poll, conducted immediately following the leak of the draft opinion, finds that while about two-thirds (64%) are aware Roe v. Wade remains the law of the land, a small share (3%) incorrectly believe it has already been overturned and another third (33%) are unsure. Women are more likely than men to say it has already been overturned or that they are not sure (40% v. 33%). Nearly half of women ages 18-49 either say it has already been overturned (6%) or they are not sure (40%).

Two-thirds of adults say it is either “very likely” (22%) or “somewhat likely” (42%) that the Supreme Court will overturn Roe this year. While few (6%) women ages 18-49 incorrectly believe Roe v. Wade has already been overturned, most say that it is “very likely” (12%) or “somewhat likely” (45%) that Roe will be overturned. About one-third (35%) of women ages 18-49 do not think this is likely to happen this year.

Supreme Court and Motivation in the Midterm Elections

If Roe v. Wade is overturned by the U.S. Supreme Court and the decision on abortion legislation is left to the states, the latest KFF polling finds a candidates’ positions on abortion could be a salient issue for a certain segment of Democratic-leaning voters but only motivates a small share of voters.

While a majority of voters (57%) say the Supreme Court overturning Roe v. Wade would not make a difference in their motivation to vote in the upcoming midterm and some (6%) say they would be less motivated, about four in ten voters (37%) say such a decision would make them more motivated to vote. As many election forecasters are projecting a Republican wave in the upcoming midterms, the poll finds the Supreme Court decision may motivate Democratic voters but fewer Republican or independent voters. More than half (55%) of Democratic voters say the Supreme Court decision will make them more motivated to vote. Majorities of Republican voters (73%), independent voters (62%), and Republican women voters (74%) say it would not make a difference to their motivation.

A majority of voters who are motivated by the Supreme Court decision are pro-choice (75%), younger (55% under age 50), half are Democrats (51%), and about four in ten are liberal (38%). Similar shares of Black voters (40%), Hispanic voters (37%), and White voters (35%) report a Supreme Court decision overturning Roe would make them more motivated to vote. In addition, about one in five voters who say they would be motivated by the Supreme Court decision are Republican (18%), want a candidate who will limit access to abortions (19%), are conservative (21%) and independent (22%).

How Candidates’ Stance On Abortion May Impact Voters

If the Supreme Court overturns Roe v. Wade, between now and the midterm elections, one would expect the issue will become more salient in the midterms with increased attention in campaign advertisements and candidate talking points.³  The KFF Tracking Poll finds this salience may play an important role in persuading a small share of voters.

About half (52%) of voters overall say they are more likely to vote for a candidate in the upcoming election who wants to protect access to abortion, about one-quarter (27%) are more likely to vote for a candidate who will limit access to abortion, and one in five voters say a candidate’s position on abortion does not matter to their vote. Eight in ten (79%) Democratic voters say that they are more likely to vote for a candidate in the upcoming election who wants to protect access to abortion, 9% prefer a candidate who wants to limit access to abortion, and 11% say a candidate’s position on abortion would make no difference to their vote. At least half of Republicans say they want to vote for someone who wants to limit access to abortion (56%), 15% prefer a candidate who wants to protect access to abortion, and a sizeable three in ten (29%) Republican voters say it does not make a difference to their vote. Half (54%) of independent voters prefer a candidate who wants to protect access to abortion while half are split between preferring a candidate who wants to limit abortion (24%) or that it does not matter to their vote (22%).

Across key demographics, groups that typically lean more Democratic consistently report they want a candidate who will protect access to abortions. For example, more than half of Black voters (58%) and Hispanic voters (52%) say they are more likely to vote for such a candidate. In addition, younger voters are more likely than their older counterparts to say they want a candidate who will protect access to abortion, with six in ten (59%) voters ages 18-49 saying they are more likely to vote for a candidate who wants to protect access to abortion, compared to less than half (44%) of voters ages 50 and older.  This age divide on the issue of abortion is consistent with other studies and this poll finds the age divide exists across partisans and gender, with younger independents, Republicans and men being more likely than their older counterparts to say that they are more likely to vote for a candidate that wants to protect access to abortion.

While the Supreme Court overturning Roe v. Wade doesn't appear to motivate a majority of voters overall, there is a small share of voters (20%) who say they would be more motivated to vote, and they would only support a candidate who shares their view, and they want candidates to protect access to abortion. This includes nearly four in ten Democratic voters, Democratic women voters, and one-fourth of women voters ages 18-49. A smaller share of voters (4%) say they are more motivated to vote by the Supreme Court decision, but in the opposite direction - to support candidates who want to limit access to abortions.

In Their OWn Words, Voters Say What About Overturning Roe Motivates Their Vote

When asked to say in their own words what it is about a Supreme Court decision overturning Roe that would make them more motivated to vote, about one-fourth cite a need to protect women’s rights to choose, rights to privacy and bodily autonomy (23%), about one in five mention wanting legislation to codify the right to an abortion or to vote for people who will protect abortion rights (18%), and 8% say that Roe v. Wade is the law and should not be overturned. About one in ten (9%) say they are motivated by wanting legislators who will ban abortions or support overturning Roe v. Wade. Five percent of voters who are motivated by Roe say that it is about having their voices heard and wanting legislators who represent their beliefs.

Public’s Opinion on Overturning Roe v. Wade, State Restrictions

KFF polling has consistently found that a majority of the public do not want to see Roe v. Wade overturned and the latest KFF poll is no different. About two-thirds (64%) U.S. adults say they do not want to see the Supreme Court overturn Roe v. Wade, while one-third of adults say they would like to see the case overturned. Majorities across gender and racial and ethnic groups say they don’t want to see it overturned, but there are differences by partisanship. Six in ten (61%) Republicans want to see the law overturned while a large majority of Democrats (85%) and six in ten independents (62%) do not want the Supreme Court to overturn Roe.

Once again, saliency lies on the side of those who want to protect abortion rights. While a large majority of Democrats (70%) say they feel “very strongly” that Roe v. Wade should not be overturned, Republicans are not as coalesced, with the about half as many Republicans (37%) feel “very strongly” that it should be overturned. A further one-quarter (24%) of Republicans feel “somewhat strongly” that Roe should be overturned, and a similar share (22%) feels “somewhat strongly” that it should not be overturned.

The public has mixed feelings on the potential for the Supreme Court to overturn Roe v. Wade and allowing states to ban abortion, with about half of adults reporting that they would feel “sad” (53%) or “angry” (47%), and fewer saying they would feel “hopeful” (34%), “indifferent” (27%) or “enthusiastic” (22%) about this decision.

Partisans have very different emotional responses to the possibility of the Supreme Court overturning Roe v. Wade, with nearly three-fourths of Democrats reporting they would be “sad” (74%) or “angry” (72%), while more than half of Republicans saying they would feel “hopeful” (57%) and four in ten would be “enthusiastic” (41%).

While a majority of women report they would be “sad” (56%) or angry” (51%) if the Supreme Court overturned Roe, there are differences among women – and men – across age groups. Majorities of adults under age 50 – both men and women – say they would feel “sad” or “angry” if Roe were overturned while four in ten older men and women say they would feel “hopeful” if this occurred.

Most Say Abortion Should Be Personal Choice Rather Than Regulated, Some Support For Limited State Regulations

Despite divided views on the future of Roe v. Wade, the public is somewhat more aligned in believing that getting an abortion should be a personal choice rather than one regulated by the government. Three in four U.S. adults say generally, getting an abortion should be a personal choice (74%), while one in four say it should be something that is regulated by law. Large majorities of Democrats (90%) and independents (74%) say it should be a personal choice, while Republicans are split (52% saying it should be a personal choice and 48% say it should be regulated by law). Eight in ten (79%) women ages 18-49 say that getting an abortion should be a personal choice, including majorities across party; nine in ten (90%) Democratic women, eight in ten (80%) independent women and about six in ten (59%) Republican women ages 18-49 say this should be a personal choice.

Awareness Of State-Specific Abortion Legislation

Just over four in ten (45%) of those living in the 17 states with laws that would likely ban abortion immediately, known as trigger laws, or abortion bans still in place since before Roe v. Wade was decided in 1973, are aware that if Roe v. Wade is overturned, abortion will no longer be legal in their state, while four in ten (42%) are not sure, and 13% say it would continue to be legal. While a small majority (55%) of women ages 18-49 in these states are aware that abortion would immediately be banned in their state, nearly half are either not sure (33%) or incorrectly believe abortions would continue to be legal (12%).

Two-thirds (63%) of those living in states where the right to an abortion is explicitly protected are aware that abortion would continue to be legal if the case was overturned, while three in ten are unsure, and few (8%) think it would no longer be legal in their state.

Large majorities of adults who reside in states with trigger laws or pre-Roe abortion bans know that for various groups of women, getting an abortion will prove more difficult in their state if Roe is overturned. In the states where the right to an abortion will be most vulnerable, eight in ten say that a Supreme Court decision overturning Roe v. Wade will make it harder for young women (82%), lower-income women (78%), Black and Hispanic women (76%), and the women in their life (77%) to get an abortion in their state.

While there is widespread awareness of the impacts on certain populations, partisans differ on their assessment of whether this is a “good thing” or a “bad thing,” with larger shares of Republicans saying it is a “good thing” that it would be harder for each of these groups to get an abortion in their state and larger shares of Democrats viewing it as a “bad thing.” Notably, at least one in five Republicans say that it would be a “bad thing” that it would be more difficult for these groups to obtain an abortion.

Among women of reproductive age in these states, about six in ten believe overturning Roe v. Wade would make abortion harder to access in their state and that this is a “bad thing”, while between two and three in ten say making abortion harder to access would be a “good thing.”

State Legislation On Abortion

The Supreme Court’s 1992 decision for Planned Parenthood v. Casey established the right of states to regulate abortion services before viability as long as the regulation does not place an “undue burden” on women seeking an abortion. “Undue burden” is shorthand for a state regulation that has been found to have the purpose or effect of placing a substantial obstacle in the path of a person seeking an abortion. Since the Casey decision in 1992, many states have enacted a wide range of restrictions such as counseling, ultrasound and waiting period requirements; parental notification and consent requirements, restrictions on insurance coverage for abortion, and regulations specific to facilities and clinicians providing abortions. If the Supreme Court overrules Roe v. Wade, states will be able to enact abortion regulations without having to pass the “undue burden” standard and states could pass restrictions that could effectively block abortion access without actually passing a ban on abortion.

Among the public, there is some support for certain state-level restrictions on women seeking abortions, but majorities of the U.S. public oppose criminalizing women, doctors, or people who assist those seeking abortion care. Waiting periods are a common regulation on abortion and 27 states have enacted waiting periods ranging from 18 to 72 hours after contacting the clinic. Two-thirds of the public (67%) support laws requiring women to wait 24 hours between meeting with a health care provider and getting an abortion. Gestational limits are another type of law that states have enacted to limit how far into a pregnancy an abortion can be performed. Recently, several states have passed laws banning abortions after the time in which fetal cardiac activity can be detected, around 6 weeks of pregnancy (which is often before a person knows they are pregnant). While many of these laws have been blocked, this type of ban on all but the earliest abortions is currently in effect in Texas. Forty-four percent of adults support laws prohibiting abortions “once a fetal heartbeat is detected, which is usually around six weeks” (44%), while 54% are opposed to these types of laws. While this is unchanged from a 2019 KFF poll, that poll found that when the public was told that six weeks is usually before many women know they are pregnant, opposition to this policy increased to six in ten.

Large majorities oppose making it a crime for doctors to perform abortions (73%) or for women to get abortions (79%). With the impending Supreme Court decision on Roe, some states have passed restrictions to ban abortions using civil enforcement and penalties. Oklahoma and Texas have laws in effect that allow private citizens to sue people who provide or abet women in getting an illegal abortion. Some state legislators have considered making it a crime to travel across state lines to obtain an abortion, but such a law is not currently in effect in any state. KFF polling finds that eight in ten oppose each of these types of laws. It is also worth noting that several states have taken action to uphold the right or expand access to abortion and also protect doctors practicing in their states from criminal or civil liabilities for performing abortions in their state.

There is also majority opposition to many of these state policies on abortion among those who reside in states where there are trigger laws or pre-Roe abortion bans. At least two-thirds of people living in these 17 states oppose criminalizing doctors for performing abortions (69%), making it a crime for women to cross state lines to get an abortion (76%), making it a crime for a woman to get an abortion (74%), or allowing private citizens to sue people who provide or assist in abortions (78%).

Partisans differ in their level of support for these state-level abortion policies. A majority of Republicans support a 24-hour waiting period (90%) and prohibiting abortions once there is cardiac activity (70%). However, less than half of Republicans now support making it a crime for doctors to perform abortions that would result in fines or prison time (47%, down from 58% in 2019), making it a crime for women to get an abortion (36%, down from 49% in 2019), allowing private citizens to sue people who provide or assist women in getting abortions (32%) or making it a crime for a woman to cross state lines to get an abortion (35%). Independents are also less likely than they were in 2019 to support laws that would criminalize doctors (25%, down from 34% in 2019). About one in five independents continue to support criminalizing women seeking an abortion (19% v. 23% in 2019).

With the exception of the law that requires women to wait 24 hours between meeting a health care provider and getting an abortion, fewer than half of Democrats and independents support these laws.

In states that have protected the right to an abortion, there is growing momentum to provide public funding to support their clinics to provide abortion care to out-of-state women who seek an abortion in their state. Among those who live in a state that has laws in place protecting the right to an abortion, majorities oppose (56%) using public funding to cover these costs. However, two-thirds (64%) would support a law that would require all employer provided health insurance plans to cover an abortion.

If abortion is banned in many states across the country, the costs associated with obtaining an abortion will increase for those who are able to travel out of state to obtain abortion services. Some employers have begun offering to cover travel expenses for employees who need to travel out of state to obtain an abortion. Asked if they would support or oppose employers paying the travel costs for an employee to travel out-of-state to obtain an abortion if abortion is not available where they reside, a slim majority (51%) of U.S. adults say they would support this and 47% oppose. Seven in ten (72%) Democrats support this, and nearly eight in ten (78%) Republicans oppose. Independents are divided, with about half saying they support (53%) or oppose (44%) this workplace benefit. Younger adults across gender are more likely than their older counterparts to support this benefit.

Gaps Remain in Public’s Knowledge About Abortion, Birth Control

This KFF poll examines what Americans know about abortion services and finds there are significant knowledge gaps on the prevalence and the overall safety of abortions.

Two-thirds of U.S. adults (64%) say that they or someone they know has had an abortion, including at least six in ten Democrats, independents and Republicans, men, and women. Yet, about half of U.S. adults (49%) incorrectly say that less than 10% of women in the U.S. have had an abortion, when the actual share is closer to one-quarter. Men are more likely than women to underestimate the share of women who have had an abortion, with six in ten (56%) of men saying it is true that less than 10% of women have had an abortion.

A large majority of the public (87%) across partisan and age groups correctly says that it is false that a woman who has gotten an abortion has a higher risk of getting breast cancer. However, a small share (9%) of all adults, rising to 13% of Republicans, believe this to be true. Three quarters (72%) of U.S. adults correctly say that a woman who has gotten an abortion will not have a harder time getting pregnant again, while one-fourth (26%) say that this statement is true, rising to one-third of  Republicans.

Many also do not know at what point in pregnancy most abortions occur. Majorities (65%) incorrectly say most abortions occur after eight weeks of pregnancy, while one-third (32%) correctly say most occur fewer than eight weeks into pregnancy. Few, however, believe that most abortions occur more than 20 weeks into pregnancy (2%).

Cost can be a barrier for women seeking abortion care, as many adults cannot afford the expense and not all health insurance plans cover abortion services. In fact, among women ages 18 to 49 who are insured, more than eight in ten (84%) say that they do not know if their insurance plan covers the cost of an abortion. Just 6% say that their insurance plan does cover the cost of an abortion, and one in ten say it does not. Most women of reproductive age do not know the cost of an abortion during the first trimester in the U.S. Just 14% correctly say that the cost out-of-pocket for a first-trimester abortion is between $500 and $700, while one-third (32%) are unsure of the cost, and many both over and underestimate the cost of this procedure.

Medication Abortion

While medication abortion now accounts for more than half of all abortions in the U.S., fewer than three in ten U.S. adults (27%) say they have heard of the medication abortion pill known as mifepristone, up slightly from 2019 (21%). Women ages 18-49 (40%) are twice as likely as women ages 50 and older (19%) and men (23%) to say they have heard of the medication abortion pill.

Of those who had heard of it, 63% (17% of total) correctly say that mifepristone can be effectively used to end a pregnancy up to the first 10 weeks. Few (12%) incorrectly say it is effective at any point during pregnancy. Six in ten of those who have heard of mifepristone (59%, 16% of total) know that a prescription is required to get medication abortion pills, while four in ten either incorrectly say it is available without a prescription (13%) or that they are unsure (28%).

Small Majorities Support requiring in-person appointments for Medication Abortion Prescriptions

Since the start of the COVID-19 pandemic, medical providers have been expanding their use of telehealth to consult with patients on issues that do not require in-person appointments. The expansion of telehealth has given some people access to health care when they otherwise would not be able to due to barriers to access, time, and distance required to travel to providers. The FDA no longer requires mifepristone to be dispensed in-person in a clinical setting, which has enabled people in many states to obtain the medications through the mail rather than having to go to a clinic or provider to receive the medication.

However, some states have explicitly banned the use of telehealth for abortion and others have instituted policies such as ultrasound requirements that necessitate the physical presence of the prescribing clinician, despite the FDA’s finding that the use of telehealth for medication abortion is safe.⁶  Among the 27% of U.S. adults who have heard of mifepristone, six in ten (16% of all adults) say they support the policy already in effect in 19 states that requires patients to have an in-person appointment to obtain a prescription for medication abortion pills, while 40% (11% of all adults) are opposed to such a requirement.

Some Confusion remains about difference between Emergency Contraceptive Pills and Medication Abortion

Some state lawmakers have discussed the possibility of placing additional restrictions or limits on the use of emergency contraceptive pills. Most U.S. adults (92%), have heard of emergency contraceptive pills, sometimes called the morning after pill or “Plan B,” similar to the share who had heard of it in 2019 and up from 85% in 2003, shortly after it was approved by the FDA. Yet some knowledge gaps remain when it comes to how the pills work. While most are aware that emergency contraceptive pills are not the same as the abortion pill (62%), and that some types are available over-the-counter without a doctor’s prescription (72%), a substantial share (73%) incorrectly think that emergency contraceptive pills can end a pregnancy in its early stages.

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted May 10-19, 2022, online and by telephone among a nationally representative sample of 1,537 U.S. adults. Interviews were conducted in English and in Spanish (n=95). The sample includes 1,285 adults reached through the SSRS Opinion Panel either online (n=1,246) or over the phone (n=39), with an oversample of women aged 18 to 49 (n=615). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to four reminder emails.

Another 252 interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). Weighting parameters included sex, age, education, race/ethnicity, region, and education. The sample was also weighted to match patterns of civic engagement from the September 2017 Volunteering and Civic Life Supplement data from the CPS. The sample was also weighted to match frequency of internet use from the National Public Opinion Reference Survey (NPORS) for Pew Research Center.  The weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

1. States that have enacted trigger bans or have a pre-Roe ban include: AL, AZ, AR, ID, KY, LA, MS, MO, ND, OK, SD, TN, TX, UT, WV, WI, WY. While Michigan has a pre-Roe abortion ban on its books, a Michigan judge recently blocked this law while litigation challenging the law as violating the Michigan State Constitution proceeds. ↩︎
2. Data and research often assume cisgender identities and may not systematically account for people who are transgender and non-binary. This survey aims to be as inclusive as possible, allowing non-binary and transgender individuals to answer questions that best reflect their identity. ↩︎
3. The Wesleyan Media Project finds that after the leak of the Supreme Court draft opinion, the number of U.S. House, Senate and gubernatorial ads mentioning abortion increased substantially, with 22% of pro-Democratic House ads and 24.5% of pro-Republican House ads mentioning abortion in the week following the opinion leak, up from 6.2% and 13.5% the week prior to the leak respectively. ↩︎
4. States that have enacted trigger bans or have a pre-Roe ban include: AL, AZ, AR, ID, KY, LA, MS, MO, ND, OK, SD, TN, TX, UT, WV, WI, WY. While Michigan has a pre-Roe abortion ban on its books, a Michigan judge recently blocked this law while litigation challenging the law as violating the Michigan State Constitution proceeds. ↩︎
5. States that have enacted protections for the right to an abortion: CA, CO, CT, DE, HI, IL, ME, MD, MA, NV, NJ, NY, OR, RI, VT, WA, DC. ↩︎
6. Laws in AZ, AR, MO, LA, TX, and WV specifically ban telehealth for abortion consultations. ND, SD, NE, KS, OK, MS, AL, TN, KY, IN, NC, and SC “have enacted laws that require the clinician providing a medication abortion to be physically present during the procedure, effectively prohibiting the use of telehealth to dispense medication for abortion remotely.” All other states allow telehealth to be used for dispensing medication abortion in line with FDA regulations. See more from a KFF fact sheet on medication abortion here. ↩︎

Community health centers are a national network of safety-net primary care providers serving low-income, medically underserved communities. In addition to providing comprehensive primary care services, health centers have aided in national, state, and local responses to the coronavirus pandemic by providing a range of services designed to slow the spread and lessen the severity of COVID-19. Based on findings from a national survey of health centers, this brief examines how the pandemic has affected health center patients and services as well as the ongoing challenges health centers and their patients face. Key findings include:

Impact of the Pandemic on Health Center Patients and Services

• Health centers increased their use of telehealth services in response to the pandemic. The pandemic necessitated a rapid expansion of health centers’ telehealth services as patients avoided in-person care due to the risk of infection, federal guidance to avoid nonessential care, and social distancing requirements. While in-person visits have rebounded, health centers’ use of telehealth services continues to be higher than before the pandemic.
• Health centers reported an increase in the number of patients seeking housing, food and nutrition, and transportation services due to the economic disruptions caused by the pandemic. Health centers provide a range of social and supportive services to complement primary care. Compared to before the pandemic, over half of responding health centers said they saw an increase in the number of patients seeking housing services, food and nutrition services, and transportation services. A majority of responding health centers reported providing health literacy (71%) and transportation services (63%) on-site, while at least four in ten reported providing SNAP, WIC, or other nutritional services (44%) and healthy food options, such as a food pantry or meal delivery (42%), on-site.
• In the wake of a growing need for mental health and substance use disorder (SUD) services during the pandemic, health centers added new services. Since the start of the pandemic, 64% of health centers reported adding at least one new mental health or SUD service (including new telehealth options). However, health centers indicated that staffing shortages and patients’ inability to access services through telehealth (e.g., due to lack of internet access or computers/phones) as the most common challenges to providing mental health and SUD services.
• The share of health centers providing medication-assisted treatment (MAT) for treating opioid use disorder (OUD) increased during the pandemic. Roughly half of health centers (48%) saw an increase in patients with OUD compared to the start of the pandemic. The number of health center patients nationally who received MAT for OUD grew by 27% from 2019 to 2020, spurred by an infusion of federal grants for behavioral health services at health centers in the years leading up to the pandemic and the ongoing need for these services.

Key Issues to Watch

• Health centers face ongoing challenges recruiting and retaining staff and financial implications related to changes to the 340B Drug Discount Program. Among responding health centers, recruiting new employees and retaining current employees were cited as top challenges by 78% and 54% of responding health centers, respectively, and are consistent with challenges reported in previous years. Looking ahead, health centers may face financial challenges as they transition out of the pandemic. A majority of health centers reported that certain actions by pharmaceutical manufacturers and pharmacy benefit managers (PBMs) related to access to and reimbursement for 340B drugs have had a negative effect on revenue.
• The unwinding of the Medicaid continuous enrollment requirement could lead to coverage disruptions for many health center patients and revenue declines for health centers. The loss of Medicaid coverage among health center patients could lead to an increase in uncompensated care costs for health centers. At the same time, the temporary infusion of federal COVID-19 grant funding for health centers will end and federal funding for some programs that helped health centers during the pandemic, such as the HRSA COVID-19 Uninsured Program, faces an uncertain future.

Introduction

Community health centers are a national network of safety-net primary care providers serving low-income, medically underserved communities. In addition to providing comprehensive primary care services, health centers have aided in national, state, and local responses to the coronavirus pandemic by providing a range of specific services designed to slow the spread and lessen the severity of COVID-19. These include providing both rapid and PCR tests, administering vaccines, and distributing masks and testing supplies and oral antiviral pills, while continuing to treat the ongoing health needs of their patients.

Additional federal grant funding made available during the pandemic has helped health centers to respond to the needs of their patients and weather the financial uncertainty related to the pandemic. However, health centers face uncertainty on a number of fronts, including the unwinding of the Medicaid continuous enrollment requirement and the loss of temporary telehealth flexibilities when the COVID-19 public health emergency (PHE) ends, as well as the lack of additional federal COVID-19 funding for programs like the Health Resources and Services Administration’s (HRSA’s) COVID-19 Uninsured program.

To understand how the pandemic has affected health center patients and services as well as the challenges health centers and their patients face, KFF and the Geiger Gibson/RCHN Community Health Foundation Research Collaborative at the George Washington University surveyed health centers in the 50 states and District of Columbia (DC). This survey was conducted in late 2021 and focused on the pandemic’s effect on services, the effects of policies on health center programs, the impact of changes made to the 340B Drug Discount Program, preparedness for the PHE unwinding, and the challenges health centers face. This brief presents survey findings for all responding health centers and also reports data from an ongoing biweekly survey conducted by HRSA.

Impact of the Pandemic on Health Centers and Their Patients

Responding to Changing Patient Needs

Health centers’ use of telehealth services increased during the pandemic. The pandemic necessitated a rapid expansion of health centers’ provision of telehealth services amid a decline in in-person visits as patients avoided in-person care due to the risk of infection, federal guidance to avoid nonessential care, and social distancing requirements. As a result, the use of telehealth increased compared to prior to the pandemic and peaked in April 2020 when more than 50% of visits on average were conducted virtually. The most recent data as of May 2022 show that telehealth visits have decreased somewhat, with about 15% of visits on average provided virtually, but still remain higher than pre-pandemic levels.

Telehealth has helped to maintain or improve access to care during the pandemic, but health centers reported challenges in providing virtual services to patients. Nearly all responding health centers cited lack of internet access among patients (97%) and lack of comfort using telehealth technology among patients (93%) as major or minor challenges to providing telehealth services (Figure 1). Additionally, over seven in ten responding health centers (72%) reported inadequate reimbursement for audio-only or telephonic telehealth services as a challenge.

Temporary policies enacted in response to the pandemic enabled health centers’ pivot to telehealth services; ending these policies could lead health centers to reduce the use of telehealth. During the public health emergency, many state Medicaid agencies, Medicare, and private insurers enacted temporary telehealth policies to improve accessibility and to provide enhanced reimbursement for telehealth. Additionally, the federal government, through the Federal Communications Commission, also provided one-time grant funding to providers (including health centers) to increase access to telehealth during the pandemic. Nearly eight in ten responding health centers (79%) reported that they would reduce the use of telehealth if these temporary telehealth flexibilities put in place by state Medicaid agencies and other payers do not remain in place.

Health centers contributed to COVID-19 vaccination, testing, and treatment efforts, reaching underserved and vulnerable populations. Supported by temporary federal grants in response to the pandemic as well as a number of national programs directly supplying health centers with tests, vaccines, therapeutics, and masks, health centers began providing new COVID-19-related services in 2020 and became an important national resource for equitably distributing these services in underserved communities. For example, according to data from a biweekly survey conducted by the Health Resources and Services Administration (HRSA), health centers have reported administering¹  more than 20 million vaccine doses (roughly 4% of all vaccinations), with more than two-thirds (69%) of vaccine doses administered to people of color. Health centers that responded to our 2021 survey reported taking actions to increase COVID-19 vaccinations uptake, including by encouraging staff to talk to patients about the vaccine during visits (96%), posting information about the vaccine on social media (92%), and conducting community outreach (71%). The HRSA survey also revealed that roughly three in ten health centers utilized mobile vans, pop-up clinics, or other events out in the community to provide the vaccine and conduct outreach in May 2022.

Increased Demand for Services

Social Services

Health centers provided a range of social and supportive services both on-site and through referrals. A majority of responding health centers reported providing health literacy (71%) and transportation services (63%) on-site, while at least four in ten reported providing SNAP, WIC, other nutritional services (44%), healthy food services (42%), and education services (40%) (Appendix Table 1). We did not ask about case management, which is a required service of the Health Center Program and should be offered on-site or through referral at all health centers.

Health centers reported an increase in the number of patients seeking housing, food and nutrition, and transportation services during the pandemic. The pandemic caused economic disruptions, particularly for lower-income workers and families and contributed to an increased need for certain social services. Compared to before the pandemic, over half of responding health centers said they saw an increase in the number of patients seeking housing services (69%), food and nutrition services (63%), and transportation services (53%) (Figure 2).

Mental Health and Substance Use Disorder Services

With an uptick in mental health problems, substance use disorders (SUD), and difficulty accessing behavioral health care during the pandemic, health centers have sought to expand access to these services. Going into the pandemic, nearly all health centers provided mental health services on-site and most provided SUD services. By late 2021, over six in ten (64%) health centers reported that they added a new mental health or SUD service. Almost half of responding health centers (47%) added individual therapy as a new service in-person, via telehealth, or both, while around one in five of responding health centers added group therapy and support groups as a new service (21% and 18%, respectively) (Figure 3). Additionally, about a third added counseling (34%) or medication (31%) for medication-assisted treatment (MAT) for opioid use disorder (OUD) as a newly offered in-person or virtual service since the start of the pandemic.

Opioid Use Disorder Services

Many health centers saw an increase in patients with OUD compared to the start of the pandemic. Health centers have historically played a significant role in addressing the opioid crisis as community-based providers with the capacity to provide medication-assisted treatment (MAT) for treating opioid use disorder (OUD). Increasingly, health centers are providing MAT, the standard of care, for OUD treatment. Prior to the pandemic, between 2016 and 2019, HRSA awarded more than $1.4 billion in federal grants to enable health centers to expand access to mental health and substance use disorder (SUD) services. Health centers used these grants to increase staff, improve the integration of behavioral health and primary care, and expand delivery of MAT services.

The number of health center patients nationally who received MAT for OUD has grown substantially during the pandemic, likely reflecting the infusion of funding for behavioral health services for health centers in the years leading up to the pandemic and the ongoing need for these services. Additionally, four in ten responding health centers saw an increase in patients with a prescription OUD and 42% saw an increase in non-prescription OUD compared to the start of the pandemic (Figure 4).

The share of health centers providing MAT increased during the pandemic. Drug overdose deaths increased by 39% nationally from March 2020 to December 2021 and, along with a reported increase in OUD patients, more health centers reported that they provided on-site MAT services for OUD. Over seven in ten (71%) responding health centers reported that their health center provides MAT medication on-site—62% provide MAT medications with OUD counseling and 9% provide only MAT medications—up from 64% in 2019 (Figure 5). The capacity of health centers to provide MAT services has also increased. Over six in ten (61%) responding health centers reported having the capacity to treat all patients who seek MAT services on-site, compared to 53% in 2019 (Figure 5).

Most health centers that provide MAT services for OUD offer more than one medication, giving providers more options to meet patients’ needs. OUD treatment includes the use of one of three medications (methadone, naltrexone, and buprenorphine) along with counseling. Of responding health centers that provide MAT services, two-thirds (67%) provided two OUD medications on-site, up from 60% in 2019, and 4% offer all three medications.

Challenges Facing Health Centers

Managing Patient Needs

While most health centers reported being able to see new patients in a timely manner for routine medical and SUD services, fewer health centers said they could schedule mental health and dental visits within two weeks. Close to three-fourths of responding health centers said that new patients could schedule a routine medical visit (76%) or SUD service visit (73%) on a walk-in basis or within two weeks (Figure 6). Smaller shares of responding health centers said that new patients could make a mental health service appointment on a walk-in basis or within two weeks (61%) and 40% said that new patients could schedule routine dental visits in the same time frame. These findings may reflect both the effects of the pandemic, as well as continuing challenges in providing these services that predate the pandemic.

Health centers reported difficulties scheduling timely medical appointments for patients with specialists outside of their health centers, especially for uninsured and Medicaid patients (Figure 7). Over eight in ten (81%) responding health centers reported that it was very or somewhat difficult to schedule an appointment with a specialist for their uninsured patients, while 63% reported difficulties scheduling appointments for Medicaid fee-for-service patients (FFS), which was comparable to the share that reported difficulties for Medicaid managed care patients (58%). Over two-thirds of health center patients are uninsured or enrolled in Medicaid. Fewer health centers reported challenges scheduling appointments for their Medicare (37%) or privately insured patients (28%). Additionally, roughly half of responding health centers said that increased availability of telehealth during the pandemic made no difference in helping to obtain timely appointments with specialists outside their organization, despite the nearly universal increase in telehealth use during the pandemic at health centers and most other outpatient providers. Only about one-third of responding health centers said telehealth made scheduling appointments with specialists outside their organization easier while 10% or less said telehealth made obtaining outside appointments harder.

Despite the increased need for certain mental health, SUD, and social and supportive services, health centers cited staffing shortages as the top challenge to providing these services (Figure 8). Almost nine in ten (85%) responding health centers cited staffing shortages as a challenge in providing social and supportive services while nearly eight in ten (79%) and seven in ten (69%) reported staffing issues as a barrier to providing mental health and SUD services, respectively. While health centers have been able to shift to telehealth, especially for mental health visits, almost half of responding health centers cited patients’ inability to access mental health and SUD services through telehealth as a common challenge (50% for mental health and 49% for SUD services). Other barriers to providing social and supportive services included lack of reimbursement, cited by 71% of responding health centers, and lack of physical space for services, cited by 67% of health centers. Fewer health centers reported these barriers to providing mental health and SUD services.

Key Issues to Watch

Health centers face new challenges related to access to and reimbursement from the 340B Drug Discount Program. The 340B Drug Discount Program provides discounted prescription medications to safety net providers, including health centers, allowing them to pass on saving to their patients and to support operations. Virtually all responding health centers (96%) reported that they participate in the 340B Drug Discount Program either through on-site pharmacies or through contracts with outside pharmacies. Among responding health centers that participate in 340B, 86% indicated that they contract with an outside pharmacy to provide 340B drugs to their patients. Recently, pharmaceutical manufacturers have limited the sale of 340B drugs to contract pharmacies. In addition, some pharmacy benefit managers (PBMs), which help to administer and manage prescription drug benefits on behalf of health insurers or state Medicaid agencies, are paying lower rates to 340B-qualified entities than to non-340B entities. Nearly seven in ten (69%) responding health centers with contract pharmacies in the 340B program reported that manufacturers’ restrictions on contract pharmacies have had a negative impact on revenue, and over half (52%) of responding health centers said PBMs’ practice of paying lower rates to 340B entities has had a negative impact on their revenue. A smaller share of responding health centers (28%) said state policy decisions to shift pharmacy benefits from Medicaid managed care to Medicaid fee-for-service had a negative effect while 44% said they did not know the impact.

The end of the continuous enrollment requirement will likely affect millions of Medicaid enrollees, creating uncertainty for health centers and their patients. 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. The current PHE is in place until mid-July 2022 though it is likely to be extended again. When the PHE ends, states will begin processing redeterminations and many health center patients could lose coverage if they are no longer eligible or face administrative barriers despite remaining eligible. Recent estimates show that between 5.3 million and 14.2 million Medicaid enrollees could lose coverage following the end of the PHE. Most health centers (66%) reported they have taken or plan to take actions to boost eligibility staff to assist their patients with renewals. However, the loss of Medicaid coverage among patients could have financial implications for health centers.

Staff recruitment and retention remain common concerns at health centers nationally. Consistent with challenges in providing key health services, among responding health centers, recruiting new employees and retaining current employees were cited as top overall challenges by 78% and 54% of responding health centers, respectively (Figure 9). These workforce issues, perennial challenges for health centers, have been exacerbated by the pandemic. Inadequate physical space (30%), decreased patient visits (24%), and changes to the 340B program (21%) were also among the top challenges for responding health centers. The share of health centers reporting increasing costs to operate health centers and a high number of uninsured patients as top challenges declined from previous years. In 2019, roughly half (52%) of health centers cited increased operating costs as a major challenge and 24% cited high numbers of uninsured patients. In contrast, in 2021, less than one-third cited increasing operational costs (whether due to COVID-19-related expenses or for other reasons) and just over 10% reported uninsured patients as a major challenge. However, the situation could shift again with the end of the public health emergency if expected coverage losses occur and lead to increased financial strain.

Conclusion

The COVID-19 pandemic has been disruptive for health centers, as for other health care providers, and health centers have adapted to meet patient needs. The pandemic led to declines in utilization of certain services and forced health centers to shift the services they offer and how they deliver care. In response, health centers pivoted to providing telehealth services and have played an active role in COVID-19 testing and vaccination efforts, aided by temporary federal COVID-19 relief funding. They have also responded to the mental health crisis that surfaced during the pandemic by increasing access to mental health, SUD, and OUD services.

Looking ahead, the financial and operational disruptions that health centers have confronted throughout the pandemic will not abate overnight when the PHE declaration ends. Patients will continue to need care, but many are likely to lose Medicaid coverage as states unwind the Medicaid continuous enrollment requirement and, in turn, health centers could see an increase in uncompensated care costs. At the same time, the temporary infusion of federal COVID-19 grant funding for health centers will end and future federal funding for some programs that helped health centers during the pandemic, such as the HRSA COVID-19 Uninsured Program, face an uncertain future. Moreover, ongoing actions by pharmaceutical manufacturers and PBMs limiting access to and reimbursement for 340B drugs have had a negative effect on some health centers’ budgets. In addition to these continued financial uncertainties, health centers are facing ongoing workforce challenges that have been exacerbated by the pandemic. How health centers transition out of the pandemic and address these concurrent challenges will affect how low-income communities access primary care and related services.

Appendix

1. Health centers report the number of vaccinations received by health center patients in the HRSA Health Center COVID-19 Survey. The survey’s questionnaire asks health centers to report the total number of patients receiving a vaccine, and HRSA has clarified that this count includes health center patients receiving vaccinations anywhere, including in settings other than the health center. However, we expect that health centers delivered the vast majority of vaccinations reported in the survey, and the number of patients reported through the survey receiving their vaccinations elsewhere is likely minimal. ↩︎