As Congress and the administration debate future funding for the global COVID-19 response, including for vaccines, we looked at how the U.S. stacks up against other donors on helping to vaccinate the world. Indeed, President Biden has convened global leaders to push for vaccination, among other COVID-19 efforts, to help achieve global vaccination coverage of 70% by September 2022, and re-emphasized the U.S.’s global efforts in the recently released “National COVID-19 Preparedness Plan”. Here, we examine how much funding for vaccines as well as vaccine doses have been allocated. For funding, we include only financial commitments made to the COVAX Advance Market Commitment (AMC); while several donors report having committed additional funds outside of the AMC for vaccine readiness and other activities (including the U.S., Germany, and Australia), there is no centralized database available with such data from all donors. For donated doses, we include those doses pledged to COVAX, other multilateral mechanisms such as the African Vaccine Acquisition Trust (AVAT), and bilaterally (see Methods for more information). We look at the overall shares provided by the U.S., as well as others, and also standardize contributions by the size of donor economies. We find that while the U.S. has contributed far more than any other donor, its rank falls considerably when standardized by GDP:

• As of March 3, 2022, donors have provided an estimated $11.0 billion in financial assistance to the COVAX AMC for vaccination efforts and pledged to donate 2.1 billion doses to COVAX, other multilateral entities, and bilaterally (see Appendix).
• By share of contributions, the U.S. ranks at the top, accounting for 36% of funding ($4.0 billion) and 41% of pledged doses (857.5 million) (see Figures 1 and 2).¹ 
• The U.S. share is greater than its share of global GDP (24%), and significantly above the next largest donor, Germany (at 11% of financial contributions and 8% of doses).
• However, when standardized by the size of the U.S. economy (per $1 million GDP), the U.S. no longer ranks at the top, falling in rank for both financial contributions and pledged doses (see Figures 3 and 4).
  • The top financial contributor, per $1 million GDP, is Sweden, followed by Norway, Kuwait, Germany, Iceland, the U.K., Canada, Italy, Switzerland, Japan, and Saudi Arabia. The U.S. ranks 12^th in financial contributions when standardized, and Sweden’s financial contribution is nearly five times that of the U.S.
  • The U.S. falls to 6^th when ranked by pledged doses per $1 million GDP and is more in line, but still lower than, other large economies such as Germany and France. By this measure, Bhutan ranks first, followed by the Maldives, Germany, France, New Zealand, and then the U.S.

As Congress and the administration continue to debate whether to provide additional emergency funding for global COVID-19 efforts, this analysis may offer new insight into considerations for future U.S. support. As we show here, the U.S. is by far the largest donor in absolute measures, but much less generous when standardized by its economy.  Of course there is no perfect metric for assessing fair share in the context of a global pandemic, and none of these measures (or those used by others in the global community) is able to fully capture both the economic and non-economic benefits that would accrue to all if COVID-19 were to truly be controlled. With only 13% of those in low and middle income countries having received at least one COVID-19 vaccine dose to date, the stakes remain quite high.

Appendix

1. While the U.S. has committed to donating more than 1.1 billion COVID-19 vaccine doses, some of these doses were purchased using funds appropriated to Gavi. For this reason, only a portion of the total 1.1 billion doses is considered a donation. ↩︎

Introduction

Guidance from the Department of Health and Human services identifies individuals with limited English proficiency (LEP) as those who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English. Individuals with LEP disproportionately experience gaps in health insurance coverage and poor health outcomes, related to difficulties in comprehending and communicating health care information. Individuals with LEP make up a disproportionate share of the Medicaid population and are more likely than English proficient enrollees to experience administrative barriers to completing Medicaid renewal processes, which may result in them losing coverage despite remaining eligible. Because people of color are significantly more likely to have LEP than White people, these barriers can also exacerbate racial and ethnic health disparities.

Provisions in the Families First Coronavirus Response Act (FFCRA) require states to maintain continuous Medicaid enrollment for enrollees until the end of the month when the COVID-19 public health emergency (PHE) ends. The current PHE was extended in January 2022.  The Biden Administration has said that it will give states a 60 day notice before the PHE expires.  Since that notice was not issued in February, it is expected that the PHE will be extended again through mid-July which would mean that the continuous enrollment provisions could expire at the beginning of August 2022 (if legislation does not pass to set an earlier end date), unless the PHE is extended again.

When the continuous enrollment requirements end and states resume redeterminations and disenrollments, individuals with LEP may be at increased risk of losing Medicaid coverage or experiencing a gap in coverage due to barriers completing these processes, even if they remain eligible for coverage. In addition to the continuous enrollment provisions, many states have leveraged Medicaid emergency authorities to expand eligibility or streamline enrollment processes during the pandemic. However, it remains to be seen whether states will maintain these processes after the public health emergency ends.

This brief examines issues to consider for maintaining coverage for eligible people with LEP when the PHE ends, including:

• Who are Medicaid enrollees with LEP?
• What barriers might people with LEP face to maintaining coverage when the PHE ends?
• How can states mitigate coverage gaps and losses for eligible people with LEP?

Who are Medicaid enrollees with LEP?

Medicaid households include a disproportionate share of nonelderly adults with LEP. Overall, 16% of nonelderly adults living in households with at least one Medicaid enrollee have LEP, meaning they reported speaking English less than very well, compared to 7% of nonelderly adults in households in which no member is enrolled in Medicaid (Figure 1). Moreover, nearly a quarter (23%) of children enrolled in Medicaid have a parent that speaks English less than very well.

The share of nonelderly adults in a household with Medicaid who speak English less than very well is higher in some states. For example, the share of nonelderly adults in Medicaid households with LEP ranges from a low of less than 1% in West Virginia to a high of 29% in California (Figure 2). Other states with relatively high shares of nonelderly adults in Medicaid households with LEP include New Jersey (25%), New York (24%), Texas (25%), Massachusetts (21%) and Florida (21%).

Most nonelderly adults in Medicaid households who have LEP are Hispanic and speak Spanish as their primary language (Figure 3). However, 16% are Asian, 7% are White and 4% are Black. While Spanish is the most common language spoken among nonelderly adults in Medicaid households who have LEP, Chinese and Vietnamese are each spoken by 3% of these adults, and there are a diverse set of languages spoken overall by this group. The other top ten languages spoken among these adults, include Arabic, Haitian, Tagalog, Korean, Portuguese, Russian and French. Moreover, the concentration of primary languages among this group will vary across areas.

What barriers might enrollees with LEP face to maintaining Medicaid coverage when the PHE ends?

All Medicaid enrollees may face administrative barriers to completing renewal and eligibility redetermination processes, but enrollees with LEP face increased risk of encountering difficulties due to language barriers. Complex enrollment and renewal processes have historically been barriers to obtaining and maintaining Medicaid coverage. Under current rules, states must first seek to renew eligibility automatically or on an ex parte basis, by checking all available data sources to confirm if eligibility can be renewed without contacting or requesting information from the family. However, due to differences in IT capabilities, states vary widely in how many renewals they are processing automatically. When a state is unable to confirm eligibility through available data sources, it must send requests for information and, in some cases, documentation to enrollees. All Medicaid enrollees may face potential challenges related to understanding redetermination processes, providing information and documentation when requested, and meeting required timeframes that can result in coverage losses among people who remain eligible. Enrollees with LEP are at particular risk for experiencing difficulties, as they may face added challenges understanding and completing tasks or forms due to language barriers, particularly if they are not provided materials translated into their language. For example, one study of Medicaid enrollees with LEP in Illinois found LEP respondents were over five times as likely to lose their Medicaid benefits compared to English proficient respondents at redetermination. The majority of LEP respondents reported having difficulty comprehending Medicaid renewal documentation and felt that completing the benefits renewal form was difficult or very difficult. Nearly half of LEP respondents also reported limited awareness of the redetermination process.

How can states mitigate Medicaid coverage gaps and losses for eligible people with LEP?

States can take a range of actions to mitigate coverage gaps and losses for eligible people when they resume eligibility determinations and renewals at the end of the PHE. The Centers for Medicare and Medicaid Services (CMS) outlined a range of policy and operational strategies for states to consider to maintain continuous coverage for eligible individuals when normal eligibility determination operations resume and specific strategies for Medicaid enrollees with LEP, including:

Streamlining renewal processes to minimize actions required by enrollees. Because enrollees with LEP may face increased difficulty understanding and completing forms or instructions, minimizing the actions people need to take to maintain coverage may be particularly helpful. States can minimize required actions by increasing the shares of Medicaid/CHIP renewals conducted automatically and simplifying processes for other renewals. CMS has identified steps states can take to increase the shares of renewals completed automatically, including expanding the types of data sources used for renewal and creating a data source hierarchy to prioritize the most recent and reliable data sources. For those renewals that cannot be completed automatically, CMS notes that states can support continuity of coverage by providing multiple modes for people to submit information (e.g., phone, mail, online, and in-person) and prepopulating forms, as required under federal rules, and by taking up other options, such as extending deadlines for response.

Facilitating access to clear and linguistically accessible communications, including notices and requests for additional information as well as throughs website and call centers. Under Title VI of the Civil Rights Act and Section 1557 of the Affordable Care Act, state Medicaid agencies are required to provide meaningful access to people with LEP. Guidance from the Department of Health and Human Services clarifies that state Medicaid agencies must take reasonable steps to ensure meaningful access to their programs by people with LEP by balancing four factors, including “1) The number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee; (2) the frequency with which LEP individuals come in contact with the program; (3) the nature and importance of the program, activity, or service provided by the program to people's lives; and (4) the resources available to the grantee/recipient and costs.”

Sharing and implementing best practices used by states in meeting language access requirements. Earlier work has identified promising practices among states to facilitate access for people with LEP, including designating staff to coordinate language services activities; involving the community to assist with planning and implementing services; creating written language access plans that identify language needs and outline strategies to meet those needs; introducing availability of language services at individuals’ first point of contact through posters or signs; utilizing bilingual staff and well as contracting out for interpreters and translators, including telephone language lines; and translating documents or providing taglines on documents to inform individuals about interpreter availability when resources are not available for full translation. For example, Colorado requires all Medicaid client correspondence to be accurately translated into the second most commonly spoken language in the state and include a tagline, translated into the top 15 languages spoken in Colorado by individuals with LEP, informing enrollees how to seek further assistance in understanding the content of correspondence. Beyond these strategies to facilitate communication with enrollees, states can also design policies to minimize coverage gaps for people with LEP. For example, Tennessee allows good cause extensions for individuals who do not complete the Medicaid eligibility determination paperwork in a timely manner if they require and are not provided assistance with English translation.

Adopting CMS suggested strategies for communicating effectively with people who have LEP to maintain coverage of eligible individuals when the PHE ends. These strategies include:

• Review their language access plans to provide written translation and oral interpretation of information and advice to individuals with LEP on how they can access free language services;
• Translate notices, forms, and other communications into multiple languages by qualified translators and review these materials for cultural competence;
• Review and enhance access to and availability of qualified oral interpreters who speak frequently spoken languages in person and through qualified telephonic interpreters, and
• Update websites with taglines in non-English languages to advise people with LEP on how they can access language services free of charge.

The Department of Justice (DOJ), also recently released recommended strategies from a federal interagency working group for improving access to public websites and digital services for people with LEP. These include making vital digital information accessible to people with LEP by translating content, prominently displaying multilingual content on websites and translating dropdown menus and search bars, ensuring translated content links to other content that is translated or communicating that the link leads to English content, and ensuring website and digital services inform people of how to access language assistance services.

Engaging with trusted community partners to conduct outreach and provide assistance. A combination of broad and targeted outreach strategies will be important for helping enrollees understand renewal requirements and maintain coverage. Working closely with community partners to conduct outreach and provide assistance will be particularly important for effectively reaching enrollees with LEP. CMS suggests states work with community-based organizations, application assisters, and providers to remind enrollees to provide updated contact information and about renewal or eligibility redetermination requirements. CMS also advises states to conduct outreach through multiple modalities, including using text messaging to send reminders to enrollees about requested information or required actions. In August 2021, CMS announced $80 million in funding for 60 Navigator programs in 30 states with Federally-Facilitated Marketplaces for the 2022 plan year, significantly higher than the annual funding awarded in 2018-2020. Navigator programs must provide information that is culturally and linguistically appropriate. Navigators can assist individuals with renewing Medicaid coverage and help those who are no longer eligible for Medicaid transition to coverage through the marketplaces, which may be particularly important for people with LEP.

With the COVID-19 pandemic came millions of job losses. But, for the first time in an economic downturn, the Affordable Care Act (ACA) was in place as a safety net, including expanded Medicaid eligibility in the 38 states and the District of Columbia that have opted for it, plus premium assistance in the ACA’s insurance Marketplaces.

Building on ACA coverage options, Congress acted earlier in the pandemic to provide continuous coverage for Medicaid enrollees in exchange for enhanced federal matching funds and to temporarily increase ACA Marketplace subsidies. To prevent Medicaid coverage losses during the COVID-19 pandemic, the Families First Coronavirus Response Act (FFCRA) of 2020 increased the federal share of most Medicaid spending on the condition that states meet certain maintenance of eligibility (MOE) requirements, including pausing Medicaid disenrollment. Additionally, the American Rescue Plan Act (ARPA) of 2021 expanded and enhanced ACA Marketplace subsidies by lowering the monthly premium enrollees are expected to pay and by extending subsidies to middle-income people who were previously ineligible for help but often priced out of the market. Of particular note, the ARPA guarantees the lowest income Marketplace enrollees have access to zero (or near-zero) dollar premium plans with very low deductibles.

Both the Medicaid MOE and the ARPA’s enhanced Marketplace subsidies are temporary and could end this year, potentially resulting in coverage loss. The Medicaid MOE is tied to the Public Health Emergency (PHE) and the ARPA’s enhanced Marketplace subsidies are currently set to expire at the end of 2022. The PHE has been extended to mid-April, but the Biden Administration has indicated that states will have 60 days’ notice before it ends, so it is expected the PHE will be extended again.  When the PHE expires, states will be able to start Medicaid dis-enrollments at the beginning of the following month and that could put millions of people at risk for losing Medicaid coverage. Medicaid enrollment has increased by over 12 million since the beginning of the pandemic. Similarly, if the ARPA’s enhanced subsidies are allowed to expire at the end of this year, the original ACA subsidies will remain in place, but millions of people could see their premium payments rise steeply, which could also lead to coverage loss. During the recent ACA open enrollment period, signups increased to 14.5 million, the highest level ever, likely due to the increased premium assistance, a longer and broader enrollment period, and stepped up outreach.

Enhanced Marketplace subsidies could act as a bridge between Medicaid and the ACA Marketplaces when the public health emergency ends. Some people who lose Medicaid coverage after the MOE ends may be eligible for employer coverage, others may still be eligible for Medicaid but could nonetheless lose coverage if they aren’t able to navigate the redetermination process, and still others will be eligible for Marketplace subsidies. If enhanced Marketplace subsidies are still in place when the Medicaid MOE ends, many people disenrolled from Medicaid could find similarly low-cost coverage on the ACA Marketplaces. If they are eligible for Marketplace subsidies, people losing Medicaid coverage may find Marketplace plans that, like Medicaid, have zero (or near-zero) monthly premium requirement and require very low out-of-pocket costs.

The Build Back Better Act (BBBA) would have continued enhanced Marketplace subsidies, but negotiations on the Hill have stalled. BBBA, as passed by the House, includes provisions that de-link the continuous enrollment and enhanced federal Medicaid payments from the PHE and set a date-certain to phase out those provisions. The BBBA also included rules to help those who remain eligible for Medicaid retain coverage. BBBA would also extend the ARPA’s enhanced Marketplace subsidies through 2025 and use Marketplace subsidies to close the Medicaid coverage gap in states that have not expanded Medicaid. However, while the BBBA has passed the House, it faces uncertain prospects in the Senate with negotiations stalled. The ACA and Medicaid provisions have not been controversial among Democratic Members of Congress, but it remains unclear if there will be a legislative vehicle to finance and enact them.

If enhanced Marketplace subsidies expire at the end of this year, low-income enrollees could still access ACA subsidies, but their transition from Medicaid as the public health emergency ends would be much more expensive. With the enhanced subsidies, a low-income person with an income of 1.5 times the poverty level ($19,320 for a single person) could get an ACA benchmark silver plan for a premium of zero or near zero and low deductibles and copays. Once the enhanced subsidies expire at the end of 2022, though, their premium payment for the benchmark silver plan would jump to over $65 per month. Many low-income people could still get a bronze plan for no premium, but those plans carry deductibles averaging about $7,000.

Continuous enrollment in Medicaid and enhanced premium assistance have helped millions afford and maintain coverage, but those gains could be reversed as the public emergency ends and if the BBBA fails to pass. The end of the public health emergency and, with it, the requirement for continuous enrollment in Medicaid will no doubt lead to coverage losses that could vary significantly across states depending on state policies as well as outreach. While many Medicaid enrollees may still be eligible, they could get caught in bureaucratic snags as renewal procedures resume and may need assistance. Provisions in the BBBA to close the Medicaid coverage gap in the dozen states that have not expanded eligibility under the ACA could provide new coverage to over two million people who currently do not have access to affordable coverage. Provisions in BBBA to continue enhanced premium assistance would also ease the transition for those no longer eligible for Medicaid. Without the BBBA, coverage losses could be significantly greater. The number of people uninsured has not grown during the pandemic and resulting economic crisis. But, perhaps ironically, we could see a big jump in the uninsured rate as the public health emergency ends if people who continue to be eligible for Medicaid are not able to retain coverage and legislation like the Build Back Better Act fails to pass.

Unlike previous recessions in modern history, this past recession was spurred by the spread of a virus (COVID-19), which created a public health crisis with unique health implications. Understanding the impact past recessions have had on Medicaid programs, early in the pandemic we began tracking employment and state revenue indicators, which can signal changes to Medicaid enrollment and have implications for state budgets. Medicaid is a counter-cyclical program, meaning that more people become eligible and enroll during economic downturns; at the same time, states may face declines in revenues that make it difficult to fund the state share of funding for the program. However, the pandemic-induced recession looked different from historical recessions in a number of ways. This brief describes the broader impacts of this most recent recession — which lasted from February 2020 to April 2020 — and also explores how trends in Medicaid spending and enrollment differed from past recessions and what that might mean for state Medicaid programs moving forward. Key differences between the Great Recession and the COVID-19 recession are highlighted in Table 1.

How were the effects of this recession different from the Great Recession?

This recession was the first recession since the passage of the Affordable Care Act (ACA), which created new coverage options in Medicaid and through the ACA marketplace (Table 1). Following the implementation of the ACA, the non-elderly uninsured rate dropped by the largest amount ever recorded, and recent data show the number of people who were uninsured and the uninsured rate held steady in 2020, the first year of the pandemic. In comparison, during the Great Recession, the non-elderly uninsured rate grew significantly by 1.9 percentage points from 2007 to 2010.

Numerous legislative actions were taken to combat the health and economic effects of the pandemic (Table 1). Congress passed the Families First Coronavirus Response Act (FFCRA), which among other provisions, authorized a 6.2 percentage point increase in the federal Medicaid match rate (“FMAP”) for states that meet certain “maintenance of eligibility” (MOE) requirements with the goal of providing broad fiscal relief to states and supporting increases in Medicaid enrollment. The additional funds were retroactively available to states beginning January 1, 2020 and continue through the quarter in which the Public Health Emergency (PHE) period ends. Congress also passed the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and later the American Rescue Plan Act (ARPA), which provided unprecedented fiscal relief, increasing the speed and strength of the economic recovery and providing support to families facing household hardships in the wake of the pandemic, including increased premium assistance for ACA marketplace enrollees. Overall, the scale of federal fiscal relief authorized during the pandemic was much larger compared to the Great Recession, providing more direct fiscal relief to families including three rounds of stimulus checks and more flexible relief for state and local governments.

What happened to Medicaid enrollment during the public health crisis and COVID-19 recession?

Medicaid enrollment has increased by over 12 million, or by more than 17 percent through July 2021 (Figure 1). Many factors likely contributed to Medicaid enrollment growth during the pandemic including the MOE and other economic factors. The MOE continuous eligibility requirement kept people enrolled in the program irrespective of changes in income and halted churn, which is when individuals temporarily lose Medicaid coverage and disenroll and then re-enroll within a short period of time. A recent KFF analysis found one in ten Medicaid/CHIP enrollees disenrolled and then re-enrolled within a year. Churn can occur when enrollees face barriers to maintaining coverage despite remaining eligible due to renewal processes and periodic eligibility checks. Churn can also occur because enrollees experience short-term income fluctuations that make them temporarily ineligible; however, much of the federal income support provided during the pandemic, like the $600 additional unemployment benefit, did not count toward Medicaid eligibility.

Despite a historical relationship between the national unemployment rate and Medicaid enrollment, studies have shown that, during the COVID-19 pandemic, increases in Medicaid enrollment have not been directly associated with increases in unemployment.^1 ,2 ,3  Employment indicators, such as the unemployment rate, have historically signaled changes to Medicaid enrollment. Following the onset of the pandemic, national employment indicators quickly worsened, creating one of the deepest recessions on record. The unemployment rate soared to a peak of 14.7% in April 2020, which is higher than the highest unemployment rate during the Great Recession (10.0% in October 2009) (Figure 1). Unemployment claims also spiked, and the employment-to-population ratio, which captures what share of the population is working overall, plummeted. While this recession was deep, it was the shortest on record at two months. National economic indicators have improved in recent months, with the national unemployment rate and monthly unemployment claims nearing pre-pandemic levels. However, the employment-to-population ratio, remains below pre-pandemic levels, signaling labor force participation remains depressed. Beyond national indicators, some states are still experiencing unemployment rates higher than the national rate.

Populations and industries affected by the recession were more likely to include people already eligible or enrolled in Medicaid. Job losses were concentrated among low-income workers, as well as workers identifying as Black or Hispanic and younger workers. While national employment indicators have improved, jobs recovery has been slower for low-wage workers compared to higher-wage workers as well as Black and Hispanic workers compared to White workers. So, even without the continuous coverage requirements, it is not clear how many Medicaid enrollees would be experiencing changes or increases in income.

The COVID-19 recession had different implications for Medicaid compared to the Great Recession.  While Medicaid enrollment growth spiked during the Great Recession (Figure 2), the MOE requirements tied to the fiscal relief during the Great Recession did not include a continuous enrollment requirement, though states could not make eligibility or enrollment processes more restrictive. As noted above, the unemployment rate peak in April 2020 exceeded the highest unemployment rate during the Great Recession; however, the Great Recession spanned a much longer timeframe with broader changes in income. The Great Recession widely impacted goods-producing industries, with the largest employment losses among the construction and manufacturing sectors, while service sectors, like leisure and hospitality, experienced the largest employment losses during the pandemic-induced recession (Table 1). During the first year of the pandemic, more women than men left the labor force, which contrasts trends seen in the Great Recession, when more men left the labor force. The Great Recession also predated the ACA, including expanded Medicaid eligibility and premium assistance for people buying individual insurance through the ACA marketplace.

What happened to Medicaid spending?

As during previous recessions, total Medicaid spending growth increased following the onset of the pandemic (Figure 2). In KFF’s annual budget survey, states identified enrollment growth as the primary driver of spending growth, and noted the end of the PHE and the MOE requirements and enhanced FMAP that are tied to the PHE will have significant implications for Medicaid spending and enrollment. Total Medicaid spending also increased during the early 2000s recession and the Great Recession, as more people experienced job or income loss and became eligible for Medicaid and enrolled. However, as the result of enhanced FMAP, state spending on Medicaid declined in 2020 as federal support increased (Figure 3). When fiscal relief expires, the state share and federal shares of Medicaid spending are expected to shift. During the Great Recession, state spending for Medicaid also declined in FY 2009 and FY 2010 due to fiscal relief from a temporary FMAP increase provided in the American Recovery and Reinvestment Act (ARRA). State spending increased sharply when that fiscal relief ended.

Improving state economic conditions as well as federal fiscal relief mitigated the need for the widespread spending cuts experienced in prior recessions. Early in the pandemic, steep state budget shortfalls were projected for FY 2020 and FY 2021 and states adopted conservative FY 2021 budgets. However, revenue declines were not as deep as projected and national tax revenue rebounded in 2021, with some declines in revenue attributed to states delaying their 2020 income tax collections from April to July (the start of FY 2021 for most states) (Figure 3). The quick rebound is due, in part, to federal aid provided to states, improved state sales tax collections on online purchases, and smaller personal income tax revenue declines due to the disproportionate impact of the pandemic on low-income workers. Revenue impacts and the speed of recovery has varied by state depending on state characteristics such as tax structure, industry reliance, social distancing policies and behaviors, and virus transmission. In contrast to budgets adopted for FY 2021, proposed FY 2022 state budgets reflected improving economic conditions, and most states enacted FY 2022 budgets with increased state spending and revenue. State revenues were slow to rebound following the Great Recession, with national revenues remaining depressed until mid-2013, though the recovery varied drastically from state to state (Table 1). Medicaid programs experienced more drastic spending cuts in previous economic downturns, including provider payment cuts, benefit restrictions, and/or eligibility restrictions.

Looking ahead

While national employment indicators show vast improvement from the start of the pandemic, there is variation across states and job sectors that may suggest slower recovery for low-wage workers; so, even after the end of the continuous coverage requirements it is unclear if Medicaid enrollment patterns will reflect broader national economic indicators. It remains unclear how long the period of recovery will last, what will happen once federal fiscal relief ends, and what longer term effects the pandemic-induced recession will have on the economy. For example, shifts in consumer and business behavior, changes in the composition of the labor force, rising inflation, and the Russian invasion of Ukraine may have future impacts on the economy.

Governors have started to propose their FY23 budgets, and their proposals will likely reflect improving fiscal conditions, with some states considering a range of tax cuts in light of improved revenue collections. During this budget season, states will likely grapple with the uncertainty of the duration of the PHE and the fiscal relief tied to the PHE, which was extended to mid-April 2022. The Biden Administration has said that it will give states a 60 day notice before the PHE expires.  Since that notice was not issued in February, it is expected that the PHE will be extended again.

The end date of the PHE will have significant implications for Medicaid enrollment and spending. When the continuous enrollment requirements end, states will begin processing redeterminations and renewals and millions of people could lose coverage if they are no longer eligible or face administrative barriers during the process despite remaining eligible. The Build Back Better Act (BBBA) – which has passed the House but faces uncertain prospects in the Senate – included provisions that would phase-out the continuous enrollment requirement with rules about disenrolling people tied to a phased down enhanced match rate through FY 2022. Within parameters set by the Administration, or legislation if enacted, states will largely be responsible for managing the unwinding of the continuous enrollment requirement, which could lead to variation in practices and in how many people are able to maintain Medicaid coverage, transition to other coverage or become uninsured.

1. Peggah Khorrami and Benjamin Sommers, “Changes in US Medicaid Enrollment During the COVID-19 Pandemic”, JAMA Network Open 4(5):e219463 (2021), doi:10.1001/jamanetworkopen.2021.9463 ↩︎
2. Chris Frenier, Sayeh Nikpay, and Ezra Golberstein, “COVID-19 Has Increased Medicaid Enrollment, But Short-Term Enrollment Changes Are Unrelated To Job Losses”, Health Affairs 39,10 (2020): 1822-1831, https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00900. ↩︎
3. Laura Dague, Nicolás Badaracco, and Thomas DeLeire, et al., “Trends in Medicaid Enrollment and Disenrollment During the Early Phase of the COVID-19 Pandemic in Wisconsin”, JAMA Health Forum 3(2):e214752 (2022), doi:10.1001/jamahealthforum.2021.4752. ↩︎

As federal, state, and local authorities move to roll back COVID-19 restrictions, a new KFF COVID-19 Vaccine Monitor survey finds many people ready to get back to normal but a public also nervous about the potential consequences. Large shares of the public are worried about the implications of both keeping and easing pandemic restrictions – with partisans split on which direction worries them the most.

Overall, majorities say they worry about the potential consequences of keeping restrictions on the mental health of kids and teenagers (65%) and local businesses’ revenue (63%). At the same time, most (61%) say that they worry that lifting restrictions will put immune-compromised people at increased risk of getting sick, and nearly half worry that it could lead to more deaths in their communities (49%) or people being unable to get needed medical care due to overwhelmed hospitals (48%).

Democrats are far more likely than Republicans to worry about the consequences of lifting restrictions on immune-compromised people (82% v. 30%), deaths in their community (70% v. 23%), and overwhelmed hospitals (66% v. 22%), while more Republicans than Democrats worry about the impact of not lifting restrictions on teenagers and children (73% v. 56%) and on local businesses (74% v. 50%).

That divide highlights the realities facing federal, state and local officials as they seek to balance public-health needs with the conflicting concerns worrying different constituencies as COVID-19 cases and deaths fall following the omicron variant surge.

“The conventional wisdom seems to be that Americans are ready to throw off all COVID restrictions and be done with it, but the survey shows that reality is much more complicated,” KFF President and CEO Drew Altman said. “Much of the public is sensibly both anxious and eager about returning to normal.”

Overall, about half (49%) of the public expects it will be safe for most people to resume normal pre-pandemic activities by late spring, including a third (35%) who say it is already safe to do so. Smaller shares expect it will be safe by mid-summer (13%) or mid-fall (5%), while a quarter (26%) say it will be at least another year before it will be safe for most people to resume pre-pandemic activities.

Republicans (65%) and unvaccinated adults (60%) are far more likely to say that it is safe to resume normal activities now than are Democrats (11%), independents (38%) and vaccinated adults (26%). Three quarters (78%) of the public – including substantial majorities across partisan groups, age, and vaccination status – expect normal life to look different going forward than it did before the pandemic.

When asked to say in their own words how normal life would be different, about 1 in 5 cite continuing to wear masks (18%) and being more cautious in their daily lives (18%). About 1 in 10 cite changes in the way we work (11%), social distancing or avoiding crowds (11%), and that everything will be different or that the current situation is the new normal (9%).

Economy/Inflation Is Voters’ Top Issue with Midterm Elections Looming, with Pandemic Well BehindWhile the COVID-19 pandemic still looms large for many people in the U.S., it is not looking like it will be a top issue for voters as they begin to think about the 2022 midterm elections.

Eight months ahead of the midterm elections, voters are focusing on other issues with large majorities saying the economy and inflation (91%), voting rights (84%), foreign policy (83%), health care costs (82%), and immigration (79%) will be at least somewhat important to their vote. The pandemic ranks lower with 69% saying it will be at least somewhat important to their vote, similar to the share who cite abortion as an important voting issue (71%). (The survey was fielded just prior to Russia’s invasion of Ukraine.)

Looking at the issues that partisan voters rate as “very” important, the economy and inflation is the top issue for Republicans (86%), while Democrats most often cite voting rights as “very important” (81%). The pandemic does not rank among the top four issues that voters in any partisan group say is going to be “very important” to their vote.

When asked about President Biden’s actions during the pandemic, similar shares of voters say he deserves more credit for helping the country through the pandemic (46%) and that he deserves more blame for hurting the country during the pandemic (41%). Democratic voters overwhelming give President Biden more credit (85%), while Republican voters overwhelmingly give him more blame (80%). Independent voters are more evenly split (41% more credit, 43% more blame).

Parents of Young Children Show Concern and Confusion About Potential Vaccine Authorization

Amid a delay in the expected authorization of a COVID-19 vaccine for children under age 5, the latest survey shows that most (57%) parents with children in that age range say they don’t have enough information about the safety and effectiveness of a vaccine for those children.

At this point, prior to federal approval of any COVID-19 vaccine for children under age 5, around two thirds (67%) of parents of children under 5 say that they are “not too confident” or “not at all confident” that the vaccines are safe for children in that age group. In addition, 39% of those parents say that the information from federal health agencies on the subject is confusing.

Reflecting those concerns, about 1 in 5 (21%) parents of children under age 5 say that they plan to get their child a COVID-19 vaccine right away once it is authorized for their age group. A quarter (26%) say they want to wait and see how it works for other young children before getting their child vaccinated, 15% say they would only get them vaccinated if required.

Parents Are Divided on Mask Requirements in Schools

With many schools around the country easing mask requirements and other restrictions, the new report shows parents are roughly split on the issue: 43% say that schools should require masks for all students and staff; 9% say they should require masks only for unvaccinated students and staff; and 46% say they should not have any mask requirements at all. That reflects falling support for masks in schools since September, when two thirds of the public and more than 6 in 10 parents favored some level of mask requirements.

Most parents say that schools should not require that students and staff get a COVID-19 vaccine, including majorities of parents with teens ages 12-17 (58%), children ages 5-11 (66%), and children under age 5 (59%). The public overall is divided on the issue, with similar shares saying schools should (46%) and should not (51%) require vaccines. Most Democrats (76%) favor a vaccine requirement in schools, while most Republicans (84%) and independents (56%) oppose one.

Three Quarters of Those Likely Eligible for a Booster Shot Report Having Gotten One

The latest report shows nearly half (47%) of all adults report having gotten a booster dose of a COVID-19 vaccine. This includes three quarters (75%) of those likely to be eligible for a booster shot because they completed their full initial vaccination at least six months ago.

Black adults (41%) and Hispanic adults (39%) continue to lag behind White adults (52%) in the share who have gotten a booster dose of a COVID-19 vaccine. These population groups were also some of the later groups to receive an initial vaccination and therefore, larger shares of them are not yet eligible for a booster dose. However, White adults (79%) continue to outpace Black adults (67%) and, to a lesser degree, Hispanic adults (69%), even among those likely eligible for a shot.

Designed and analyzed by public opinion researchers at KFF, the Vaccine Monitor survey was conducted from February 9-21, 2022 among a nationally representative random digit dial telephone sample of 1,502 adults. Interviews were conducted in English and Spanish by landline (172) and cell phone (1,330). The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher.

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and hesitancy, trusted messengers, and messages, as well as the public’s experiences with vaccination.

While momentum to enact the Build Back Better Act (BBBA) has stalled in Congress, public support for  legislation to lower prescription drug costs is likely to persist, particularly in light of concerns about rising prices due to inflation. The House-passed BBBA would allow the federal government to negotiate drug prices in Medicare, cap Medicare beneficiaries’ out-of-pocket drug spending under Part D, cap monthly insulin costs, and require drug companies to pay rebates to the federal government when annual increases in drug prices for Medicare and private insurance exceed the rate of inflation.

As context for understanding the possible impact of the inflation rebate proposal, this analysis compares price changes for drugs covered by Medicare Part B (administered by physicians) and Part D (retail prescription drugs) between 2019 and 2020 to the inflation rate over the same period (1%) (prior to the recent surge in the annual inflation rate, which is currently 7.5%). Our analysis is based on changes in unit prices reported in the most recent drug spending data released by the Centers for Medicare & Medicaid Services (CMS) through 2020. For Part D, prices are based on total gross spending, including Medicare, plan, and beneficiary spending, but not reflecting manufacturer rebates and discounts to plans because they are considered proprietary and therefore not publicly available. For Part B, prices are based on total spending, including beneficiary liability and Medicare’s payment, which is based on the average sales price; this measure takes rebates and discounts into account. We believe our approach to measuring price changes is reasonable because the BBBA’s inflation rebate proposal for Part D drugs is based on changes in the average manufacturer price, which also doesn’t take rebates paid to plan sponsors or pharmacy benefit managers into account; and for Part B drugs, is based on changes in the average sales price. (See Methods box for additional details.)

Price Increases Outpaced Inflation for Half of all Drugs Covered by Medicare in 2020

Half of all Part D covered drugs (50% of 3,343 drugs) and nearly half of all Part B covered drugs (48% of 568 drugs) had price increases greater than inflation between July 2019 and July 2020, which was 1.0% (Figure 1).

Among the 1,947 Medicare-covered drugs with price increases above the rate of inflation in 2020, one-third (668 drugs) had price increases of 7.5% or more – the current annual inflation rate.

Among drugs covered under Part D, 17% (567 drugs) had price increases of 7.5% or more between 2019 and 2020; 11% (1,106 drugs) had price increases above the rate of inflation but below 7.5%; 9% (285 drugs) had price increases below inflation; and 41% (1,385 drugs) had price reductions.

For Part B drugs, 18% (101 drugs) had price increases of 7.5% or more between 2019 and 2020; 30% (173 drugs) had price increases above the rate of inflation but below 7.5%; 6% (35 drugs) had price increases below inflation; and for the remaining 46% (259 drugs), prices decreased.

Across all Part D drugs with price increases greater than inflation, the median price increase was 5.6%; for Part B, the median price increase was 5.4%.

Prices Rose Faster Than Inflation for Most of the 25 Top-Spending Drugs in Both Part B and Part D in 2020

In terms of drugs with the highest total spending, 23 of the top 25 Part D drugs and 16 of the top 25 Part B drugs had price increases above inflation between 2019 and 2020 (Figure 2).

Among the 25 drugs covered by Medicare Part D with the highest total gross spending (not accounting for rebates), 23 had price increases greater than inflation in 2020 (Table 1). This includes the top 3 drugs by total gross spending in 2020: Eliquis, a blood thinner used by 2.6 million beneficiaries in 2020, with a 5.9% price increase; Revlimid, a treatment for multiple myeloma used by nearly 44,000 beneficiaries in 2020, with a 6.5% price increase; and Xarelto, a blood thinner used by 1.2 million beneficiaries in 2020, with a 4.1% price increase.

Among the 25 drugs covered by Medicare Part B with the highest total spending, 16 had price increases greater than inflation in 2020 (Table 2). This includes 2 of the top 3 drugs by total spending in 2020: Keytruda, a cancer treatment used by nearly 59,000 beneficiaries in 2020, with a 3.3% price increase in 2020; and Prolia, a treatment for osteoporosis used by nearly 600,000 beneficiaries in 2020, with a 4.7% price increase in 2020.

While drug price inflation based on changes in spending per dosage unit may appear relatively modest in dollar terms for many of the top spending drugs, administration or use of most of these drugs requires multiple dosage units. This means that a relatively small price change per dosage unit can translate to a large change in overall spending per claim.

• For example, the $50 increase (6.5%) in the average spending per dosage unit for Revlimid translates to an increase of more than $1,000 per claim (from $15,178 in 2019 to $16,237 in 2020) and nearly $12,000 in higher total costs per user in 2020 compared to 2019 (from $110,713 to $122,432). (Although these total spending amounts for Part D drugs do not account for rebates, for many higher-cost specialty drugs with less competition, like Revlimid, rebates are likely to be quite low.)
• Similarly, while the price per dosage unit for the Part B drug Keytruda increased by only $1.44 (3.3%) between 2019 and 2020, from $43.87 to $45.31, this price increase contributed to an increase of nearly $750 in average spending per claim (from $9,102 in 2019 to $9,843 in 2020) and an increase of nearly $6,000 in average spending per user (from $53,745 in 2019 to $59,642 in 2020).

Annual increases in drug price increases can translate to higher Medicare spending and higher out-of-pocket drug costs by patients. Higher out-of-pocket spending occurs when beneficiaries are required to pay coinsurance, or a percent of the drug’s price – which is common for many brand-name Part D drugs and standard for all Part B covered drugs in the form of a 20% coinsurance requirement.

The Congressional Budget Office estimates a net federal deficit reduction of $83.6 billion over 10 years (2022-2031) from the drug inflation rebate provisions in the BBBA for Medicare and private insurance. Actual savings would depend in part on the degree to which drug price increases exceed the inflation rate. In periods when inflation is running low, as it was in 2019-2020, even relatively modest drug price increases would trigger inflation rebates. But in periods of high inflation, as it is currently, only more sizable drug price increases would trigger rebates. In the absence of Congressional action on prescription drug proposals, rising drug prices are likely to continue to pose affordability challenges for many people.

Tables

This infographic looks at the persistent disparities in health and health care for Black people, which reflect structural and systematic inequities rooted in racism and discrimination. Although disparities in health coverage for Black people narrowed after passage of the Affordable Care Act, they continue to face higher rates of illness and death compared to White people. Black people are also more likely to experience barriers to receiving care and face discrimination while seeking care for themselves or a family member. Inequities outside the health care system – in terms of measures like poverty, food insecurity, and family wealth – also negatively affect the health of Black families.

The COVID-19 pandemic has brought to the forefront and exacerbated underlying health and health care disparities for Black people. Addressing these disparities is key to improving the health and well-being of Black people. (Click on a slide below to expand for a larger view).

The source charts for this infographic can be found in these reports:

• Key Facts on Health and Health Care by Race and Ethnicity
• Taking A Closer Look At Characteristics of People in the Coverage Gap
• KFF/The Undefeated Survey on Race and Health
• Latest Data on COVID-19 Vaccinations by Race/Ethnicity, February 2022

Medicaid, the nation’s health coverage program for poor and low-income people, provides millions of low-income women across the nation with health and long-term care coverage. Women comprise the majority of the adult Medicaid population, and the program offers coverage of a wide range of primary, preventive, specialty, and long-term care services that are important to women across their lifespans.

The diverse population of women covered by Medicaid face many social, economic, and health challenges that affect their ability to receive timely and high-quality health care. In 2020, Medicaid covered 16% of nonelderly adult women in the United States, but coverage rates were higher among certain groups, such as those in fair or poor health, women of color, single mothers, low-income women, and women who have not completed a high school education.

Nearly one in four COVID-19 deaths has been in a long-term care facility since the start of the pandemic. Due to the disproportionate impact of COVID-19 on this population, nursing home residents and staff were prioritized to receive the vaccine when the vaccine rollout began in Winter 2020-2021. Since then, CMS has implemented a health care worker vaccination mandate for providers that participate in Medicare and/or Medicaid. Although some states have sued to challenge this rule, it was recently allowed to take effect by the Supreme Court.

In part due to the litigation, facilities in different states have different deadlines to comply with the new rule. CMS guidance requires staff to have received their first vaccine dose or have a pending or approved exemption by January 27^th in 26 states (25 states plus D.C.), including 25 that did not sue to challenge the rule, and Florida, where courts refused to block the rule. Additional CMS guidance sets a February 14^th deadline for staff to have received their first vaccine dose or have a pending or approved exemption request after the Supreme Court allowed the rule to take effect in 24 other states that challenged the rule. Finally, CMS guidance sets a February 21 deadline for Texas, where a lawsuit was dismissed after the Supreme Court’s decision. All guidance specifies that if by the dose one deadline, a facility is above 80%, and has a plan to achieve a 100% single-dose staff vaccination rate within 60 days of the deadline, they will not be subject to additional enforcement action.

This data note presents completed vaccination and booster rates among nursing home staff, by state. This analysis does not categorize states or facilities by compliance since deadlines for all states have not passed and facility-level data is lagged. This analysis presents data on completed vaccinations at the state-level rather than at the facility-level, though this policy will be enforced at the facility-level. Future analyses will evaluate the share of facilities in each state in compliance with the rule once compliance deadlines for both doses have passed.

Completed vaccination refers to those who have completed a 2-dose Pfizer, 2-dose Moderna, or a single dose of J&J. Booster data reflect any additional dose of vaccination. This analysis uses federal nursing home data as of January 30^th, 2022 to calculate staff vaccination and booster rates among the 26 states with the January 27^th first-dose deadline, and as a baseline for assessing the remaining 25 states with first-dose deadlines that follow in February. The analysis is based on 10,627 nursing homes reporting complete data (approximately 70% of all nursing homes). The data in this piece were reported after the January 27 dose one deadline in 26 states; the dose one deadline has not yet passed in the remaining 25 states, as noted above. Table 1 provides detailed state-level data.

As the deadline for first doses for health care workers passed in 25 states + D.C., and approached in the remaining states, nursing home staff completed vaccination rates varied widely by state, ranging from 70% in Ohio to 99% in Maine, Rhode Island, New York, and Massachusetts for the week ending January 30^th, 2022 (Figure 1 and Table 1). Nationally, the nursing home staff vaccination rate is about 84%. Twenty-three states reported staff vaccination rates higher than the national average. Of these 23 states, 14 states plus D.C. reported staff vaccination rates of over 90%. Four states reported a near-universal staff vaccination rate of 99%. Twenty-six states reported staff vaccination rates lower than the national average, with 16 of these states reporting even lower staff vaccination rates under 80% (Figure 2). All 16 of these states are located in the South, Midwest, and Rocky Mountain regions of the U.S. (Figure 2). CMS cited variation in staff vaccination rates by state and region as a factor leading to the adoption of the rule.

The 26 states that were subject to the January 27^th deadline for the first dose of the COVID-19 vaccine reported higher completed vaccination rates (89%) than the 25 states subject to the February deadlines (77%) (Table 1). In the 26 states where staff were required to receive their first dose by January 27^th, the completed staff vaccination rate was 89% as of January 30^th. Nursing homes in the remaining 25 states subject to the February deadlines – February 14^th (24 states) and February 21^st (1 state) – reported a lower staff vaccination rate of 77%, likely reflecting a mix of federal mandate deadlines not yet passing, a lack of state and/or local mandates, and different degrees of vaccine hesitancy among staff.

While the new CMS rule does not require staff to receive booster shots, nursing home staff booster rates also vary across states, ranging from 17% in three states (Louisiana, Missouri, and Mississippi) to 56% in California (Figure 1 and Table 1). Nationally, booster rates among nursing home staff are about 28%. These values represent the share of all staff who have received their booster, although some who were vaccinated more recently may not have been eligible for their booster by January 30^th (the most recent data published). Individuals who received the Pfizer-BioNTech or Moderna vaccines become eligible for boosters five months after completing their primary vaccination series. Individuals who received Johnson & Johnson’s Janssen vaccine are eligible for boosters two months after receiving their shot. States with the earlier dose one vaccination deadline also report higher booster rates than states with a later dose one vaccination deadline. State level variation in booster rates may reflect differences in attitudes or hesitancy about boosters.

In the aftermath of the Supreme Court’s decision allowing the rule to take effect, litigation challenging this rule continues in Louisiana, where 14 states challenging the rule are seeking to add new claims to their lawsuit, and Tennessee and Virginia are seeking to join the challengers' case against the federal government. The rule, which was issued as interim final, may also be revised as CMS reviews public comments before issuing a final rule. As the various deadlines pass, nursing homes could be subject to enforcement of this rule through a number of mechanisms, including civil monetary penalties, denial of payments, and termination of participation from the Medicare and Medicaid programs. CMS guidance emphasizes that their “primary goal is to bring health care facilities into compliance” and  termination would likely occur “only after providing a facility with an opportunity to make corrections and come into compliance.” When issuing the rule, CMS acknowledged that some staff may leave their jobs because they do not want to receive the vaccine but cited examples of vaccine mandates adopted by health systems in Texas and Detroit and a long-term care parent corporation with 250 facilities as well as the New York state health care worker mandate, all of which resulted in high rates of compliance and few employee resignations. As with other Medicare and Medicaid federal provider requirements, state surveyors will have primary responsibility for enforcing the rule as part of routine inspections. However, CMS has notified states that it may reduce the amount of federal money that states receive to support facility oversight and redirect those funds to support federal oversight activities if states do not include facility compliance with all federal requirements in their oversight.