More than 200,000 long-term care facility (LTCF) residents and staff have died due to COVID since the start of the pandemic (Figure 1). The CDC’s latest update reporting data on nursing home deaths as of January 30^th pushes the reported number of deaths over this bleak milestone. This finding comes at a time when the national surge in cases due to the Omicron variant has started to subside, deaths are rising nationwide, and nursing homes have been working to increase vaccination and booster rates among residents and staff, particularly in light of the new federal rule requiring staff vaccination recently allowed to take effect by the Supreme Court. As of January 16^th, approximately 82% of nursing home staff and 87% of nursing home residents are fully vaccinated.

This death count is based on state and federal data sources. For the period between March 2020 and June 2021, the total number of deaths is based on state-reported data on LTCFs, including nursing homes, assisted living, and group homes, that summed to 187,000 resident and staff deaths. For the subsequent period between July 2021 and January 2022, we incorporated data reported to the federal government by nursing facilities (excluding other types of LTCFs), adding another 14,000 resident and staff deaths to the total. The total number of resident and staff deaths from these two sources, roughly 201,000, is likely an undercount of the true number of resident and staff deaths in LTCFs since it excludes deaths in long-term care settings other than nursing homes after June 30^th, 2021. Additionally, not all states reported data on all types of LTCFs prior to June 2021.

COVID-19 deaths in LTCFs make up at least 23% of all COVID-19 deaths in the US (Figure 1). This share has decreased since the start of the pandemic, when LTCF deaths were nearly half of all deaths nationally. This share has dropped over time for a number of reasons, including high rates of vaccination among residents, rising vaccination rates among staff, an increased emphasis on infection control procedures, declining nursing home occupancy, and the lack of data on deaths in assisted living and LTCFs other than nursing homes in recent months. Despite this drop as a share of total deaths, nursing homes have continued to experience disproportionately high case and death rates in the country during the recent surge. Higher case rates may be attributed to the highly transmissible nature of Omicron and the nature of congregate care settings. Higher death rates may be attributed to the high-risk status of those who reside in nursing homes.

COVID-19 data that includes settings across the care continuum is essential to comprehensively assess the impact of COVID-19 on seniors and people with disabilities. To date, the federal government only requires data on COVID-19 cases, deaths, testing, and vaccinations from Medicare and Medicaid-certified nursing facilities. However, there is ample research suggesting that that LTSS users in congregate community based settings outside of nursing homes also face elevated risks of COVID-19 infection due to health conditions and the higher levels of infection transmission in some non-nursing facility congregate settings such as assisted living facilities and group homes. Nearly one million people live in assisted living facilities, a population roughly the size of the nursing home population, but one that lacks comparable data. The data gap for all settings across the care continuum makes it difficult to assess the full impact of the pandemic on seniors and people with disabilities residing outside of nursing homes. Additionally, the federal health care worker vaccine mandate does not apply to all settings across the care continuum, possibly leading to COVID-19 infections with resulting staff shortages in these settings.

Data is not available on the demographics of those who died in long-term care settings, making it difficult to understand the impact of race/ethnicity, age, vaccination status, and other key characteristics on infection severity or likelihood of mortality in LTCFs. While federally available data provides insight into the numbers of cases, deaths, and vaccinations as reported by nursing homes, gaps in data limit the ability to assess the impact more directly among residents and staff, by patient characteristics. Overall, cases and deaths in nursing homes appear to be declining. However, this analysis confirms the disproportionate toll of COVID-19 on people living and working in LTCFs and highlights the importance of comprehensive, timely, and accurate data.

In these brief videos, KFF Director of Public Opinion and Survey Research Liz Hamel examines Vaccine Monitor data to show how uptake of COVID-19 vaccines has changed over time, including the latest push for booster shots. The videos are the latest in the In Focus with KFF series, which features insights from our experts on health care issues in the news.

How has the makeup of who is vaccinated changed over time?

What has convinced people who were initially hesitant to get a COVID-19 vaccine?

Who is likely to have received a COVID-19 booster dose?

3 in 10 of Those with Children Under 5 Expect to Get Them a Shot Right Away Once Eligible

1 in 4 Parents Say Their Student Had to Quarantine in January Due to COVID-19 Infection or Exposure; Overall 4 in 10 Report Some Education Disruption

Growing shares of parents say that their eligible children have gotten at least one dose of a COVID-19 vaccine, and three in ten parents with children under age 5 say they want to get their child vaccinated immediately once they become eligible, a new KFF COVID-19 Vaccine Monitor report shows.

Among parents with children ages 12-17, 61% now say that their child is vaccinated, up from 49% in November. Another 3% now say they plan to get their child vaccinated as soon as possible, and 6% say they want to “wait and see” how it works for others before doing so. Nearly a quarter (23%) of parents with adolescent children say they definitely will not get them vaccinated, while a small share (4%) say they will only do so if it is required for school.

Adolescents and teenagers in this age group are also encouraged to get a booster shot six months after their initial vaccination. One in five (21%) parents with vaccinated children in that age range say their child has already received a booster, while most others say they definitely (41%) or probably (24%) will get them a booster shot.

Among parents of children ages 5-11, who became eligible for a COVID-19 vaccine in early November, a third (33%) say their child is now vaccinated, twice the share that said so in November (16%). In addition, 13% now say they want to get their child vaccinated “right away”, and 19% say they want to “wait and see” before doing so. Others are more resistant, with a quarter (24%) saying they “definitely will not” get their child vaccinated and 9% saying they would “only do so if required for school.

While children under age 5 are not yet eligible to receive any COVID-19 vaccine, three in ten (31%) parents of children that age say they would get their child vaccinated “right away” when able. A similar share says they would want to “wait and see” how it works for other young children first, while a quarter (26%) say they would “definitely not,” and 12% say they would do so “only if required.

Since schools reopened in January after the holidays, more than a quarter (27%) of parents say their child has had to quarantine at home because they tested positive for COVID-19 or were exposed to someone who tested positive, the new Vaccine Monitor survey finds.

In addition, one in five parents (20%) say their school shut down in-person classes or switched to virtually learning at some point in January, and 14% say they kept their child home from school because of the risks of getting COVID-19.

Combined, 41% of parents report at least one of those three types of disruption with their child’s education. This includes half (49%) of Black and Hispanic parents, who are much more likely than White parents to say they kept a child home from school because of the COVID-19 risks (28% and 7%, respectively).

Overall half (50%) say they are worried their child will get seriously ill from COVID-19, including a quarter (25%) who say they are “very worried.” Black and Hispanic parents are also much more likely to be worried about this than White parents (70% and 39%, respectively).

Other findings include:

• About one in seven (14%) parents of unvaccinated children ages 5-17 say that news about the omicron variant makes them more likely to get their vaccinated, while a large majority (79%) say that it makes no difference.
• 3 in 10 (30%) parents of children enrolled in school say their child’s school provided COVID-19 tests for students to take either in person or at home before returning to school after the winter holidays. In addition, about 4 in 10 (39%) parents of children enrolled in school say they tried to purchase an at-home test kit in the past month.

Designed and analyzed by public opinion researchers at KFF, the KFF Vaccine Monitor survey was conducted from January 11-23, 2022 among a nationally representative random digit dial telephone sample of 1,536 adults, including 420 parents or guardians of children under 18. Interviews were conducted in English and Spanish by landline (165) and cell phone (1,371). The margin of sampling error is plus or minus 3 percentage points for the full sample, and plus or minus 6 percentage points for parents of children under 18. 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 acceptance, information needs, trusted messengers and messages, as well as the public’s experiences with vaccination.

Across the country, many Americans are having difficulty accessing COVID-19 tests amid the ongoing surge in cases driven by the new Omicron variant. The Biden administration has taken a multi-pronged approach to increase access to COVID-19 tests that includes allowing every household to order up to four free at-home tests, increasing testing in schools, expanding the number of federal testing sites, and requiring private insurers to cover the costs of at-home tests. In addition, under the American Rescue Plan Act (ARPA), state Medicaid and Children’s Health Insurance Program (CHIP) programs are required to cover FDA-authorized at-home COVID-19 tests without cost-sharing. As part of an effort to promote equitable access to tests, the administration also launched a testing supply program in late December that has set aside 25 million rapid at-home self-test kits (or 50 million tests because there are two tests per kit) for distribution by the more than 1,300 community health centers.

Health centers are a national network of safety-net primary care providers that have played a significant role in the COVID-19 response, including facilitating equitable access to vaccinations. To date, health centers have administered nearly 19 million doses of the vaccine, of which more than two-thirds (68%) have gone to people of color. While health centers make up a relatively small proportion (4%) of total vaccinations administered nationally (roughly 530 million doses administered as of mid-January), health centers’ role has focused on vaccinating and providing primary care to some of the hardest-to-reach populations.

Like the vaccine program, the objective of the health center COVID-19 testing supply program is to provide COVID-19 rapid self-tests to communities that are currently facing difficulties accessing COVID-19 tests. Under the program, health centers will be distributing self-tests to patients and community members, with a focus on populations at greatest risk from adverse outcomes related to COVID-19. While the 25 million test kits set aside by the administration for the program is notably less than 28.6 million patients served by health centers in 2020, the federal government expects the number of test kits for the program to last through May 2022. The self-tests provided through the new federal program should supplement other testing services that health centers have been providing throughout the pandemic. Beyond the supply of free self-tests available through the new program, health center patients with Medicaid, CHIP, or other coverage may have other options to access these free tests through pharmacies or other sources and health centers may be able to seek reimbursement from public and private payers, including Medicaid/CHIP reimbursement, for self-tests ordered for patients covered by these programs depending on state rules.

Data collected through a biweekly survey conducted by the Health Resources and Services Administration (HRSA) show that health center patient demand for COVID-19 tests has increased recently (as it has across the US). In the two weeks ending January 14, 2022, health centers reported administering an average of 794 PCR and antigen tests per responding health center, more than double the number reported in the December 17, 2021 survey. Notably, roughly two-thirds (64%) of tests were provided to people of color. These data indicate that supplying health centers with self-test kits should further increase access to testing in underserved communities during the current period of high demand.

HSRA’s most recent biweekly survey also shows how health centers are distributing the self-test kits through the federal partnership program as of early January. In the two weeks ending January 14, 27% of responding health centers reported distributing 1.08 million kits to community members (or roughly 2 million tests because each kit includes two tests). That number is expected to increase as more health centers register for the program and begin placing orders. Health centers also reported that they distributed the self-tests in a variety of ways (Figure 1). Most reported passing out the test kits to existing health center patients (83%) or to others in the community who came to the health center (61%). Roughly one-third (32%) of health centers reported distributing tests through direct outreach to underserved populations, such as individuals experiencing homelessness, migrant farmworkers, and low-income populations.

Looking ahead, health centers are expected to participate in other efforts to slow the spread and lessen the severity of COVID-19 disease. HRSA has begun the initial phase for a separate program that supplies health centers with oral antiviral pills to treat patients who recently tested positive for COVID-19 to lower their risk of more serious illness. The initial phase of this program includes 200 health centers; HRSA will include more participants as supply of the antivirals increases. In the most recent biweekly survey of health centers (as of January 14), 59 health centers had begun distributing antiviral pills through the new program, a number that we expect will grow as the program ramps up. In addition to supplying self-tests and antiviral pills, the administration recently began distributing N95 masks through community health centers alongside retail pharmacies, another program that should be ramping up in coming weeks.

Health centers are growing their role in the nation’s pandemic response efforts (in addition to state and local efforts) and have been important players in coordinating response efforts quickly and more equitably. Taken together, health centers’ federal partnership programs to administer vaccinations, distribute self-test kits, provide free N95 masks (in the coming weeks), and eventually prescribe and distribute oral antivirals should strengthen health centers’ ability to help prevent, detect, and treat COVID-19 in underserved communities.

The Biden Administration announced 14.5 million people have signed up for Affordable Care Act Marketplace coverage for 2022. This represents a 21% increase in Marketplace sign-ups over last year. Three states (Massachusetts, Kentucky, and Hawaii) and Washington, DC, saw enrollment decrease from 2021 to 2022. The remaining 47 states saw Marketplace enrollment increase, ranging from 1% in Rhode Island to 42% in Texas. In 20 states, enrollment increased by more than 20%.

In terms of numbers of people, Florida saw the biggest increase with 603,000 more sign-ups than last year. That was followed by Texas (549,000) Georgia (184,000), California (156,000), and North Carolina (134,000). In the places where enrollment shrunk, sign-ups decreased by 31,000 in Massachusetts, followed by Kentucky (-4,000), Washington, DC (-1,000), and Hawaii (less than 600).

The increase in Marketplace enrollment is due to expanded premium subsidies for 2021 and 2022 passed through the American Rescue Plan Act (ARPA), and increased efforts to enroll eligible people. ARPA increased premium subsidies for eligible enrollees and made premium subsidies available to middle-income enrollees to purchase coverage through Marketplaces. Additionally, the Biden Administration increased marketing and outreach efforts, including by increasing navigator funding and extending open enrollment by 30 days.

Of note, the reported enrollment is based on the number of people who signed up for coverage on state and federal Marketplaces through January 15, 2022. Open enrollment is ongoing beyond January 15 in some state Marketplaces (including California, Kentucky, Maryland, New Jersey, New York, Rhode Island, and DC). Colorado, Maryland, New York, and DC have also established special enrollment periods for the COVID-19 pandemic that allow uninsured people to buy coverage outside of the open enrollment period. Therefore, final Marketplace sign-ups for 2022 may be higher.

6 in 10 Who Tried to Purchase an At-Home Test and a Third Who Sought an In-Person Test Say It Was Difficult to Find, Though Most Were Eventually Able to Get a Test

Black and Hispanic Adults are More Likely Than White Adults to Worry About Omicron’s Effects, Including Becoming Seriously Ill or Missing Work Due to Infection

The latest KFF COVID-19 Vaccine Monitor report shows that 42% of all adults nationwide have received a COVID-19 booster and more than three quarters (77%) have received at least one dose of a COVID-19 vaccine, up slightly since November (73%) before the omicron variant triggered a surge in cases, hospitalizations and deaths.

The small shift comes after vaccination rates stagnated in the fall but leaves relatively few unvaccinated adults who are open to getting a shot. Just 1% plan to do so right away, 4% want to wait and see how it works for others, and 3% who say they would only do so if required for work, school or other activities. About 1 in 7 adults (14%) say they “definitely will not” get a vaccine, a share that is largely unchanged since December 2020.

The survey also finds most vaccinated people are getting recommended booster shots. Overall, 42% of the public (and 55% of all vaccinated adults) say they’ve received a booster dose.

Mirroring their early uptake of the initial vaccine, two thirds (66%) of all adults ages 65 and older and half (50%) of adults ages 50-64 received a booster. Similarly, Democrats (62%) are more likely than independents (37%) and Republicans (32%) to have received a booster.

Among the population likely to be booster-eligible (those who either received a booster or completed a full initial course of vaccination at least 6 months ago), 7 in 10 (70%) have gotten a booster. This rises to 86% among those ages 65 and over and 77% among those ages 50-64 who are likely booster-eligible.

Across racial and ethnic groups, White adults (46%) are more likely than Black (31%) and Hispanic (37%) adults to have received a booster. This may at least partially reflect some Black and Hispanic adults not yet being eligible for a booster if their initial course of vaccination was completed recently. However, there is evidence that booster uptake and access may be lagging among the booster-eligible population of Black adults. Among the likely booster-eligible population, 57% of Black adults compared with 69% of Hispanic adults and 72% of White adults have gotten a booster.

Amid the Omicron Surge, Many Report Challenges to Accessing COVID-19 Tests

With COVID-19 cases surging to unprecedented levels, nearly half (48%) of adults say that in the past month they tried to get either an in-person COVID-19 test (33%) and/or an at-home test (28%).

Fielded as the Biden administration began to encourage more widespread testing and put forward policies to improve access, the report highlights people’s struggles to obtain tests when needed.

While most (65%) who tried to find an in-person test in the past month say it was easy to do, a third (35%) say it was difficult. Rapid at-home tests presented even more of a challenge, with most (62%) who tried to get one saying it was difficult and a little more than a third (38%) saying it was easy.

Importantly, the vast majority (89%) of those who attempted to get an in-person COVID-19 test in the past month say they were able to get one. Still 11% of those who tried to get such a test (4% of all adults) say they were unable to get an in-person test, and 23% (7% of all adults) say they had to wait two days or more to be tested.

One-third of those who tried to get an at-home test (9% of all adults) say they were unable to get one, mainly because tests were not available rather than being too expensive (91% vs. 2% among those who tried but could not get an at-home test).

When asked who is responsible for the limited availability of COVID-19 tests, about half say the U.S. Food and Drug Administration (FDA) deserves at least a fair amount of blame. Slightly fewer think President Biden (44%) or test manufacturers (41%) deserve at least a fair amount of blame. The survey was in the field when President Biden announced that people could begin to order free at-home tests on January 19.

Black and Hispanics Adults Are More Worried than White Adults About Omicron’s Impact on Them

About 4 in 10 adults (42%) say they are at least somewhat worried about getting the omicron variant, though fewer worry about having to miss work (36%), becoming serious ill (34%), or being hospitalized (27%) as a result of a coronavirus infection.

Black and Hispanic adults, as well as people with lower incomes, are more likely to worry about each of these. For example, most Hispanic (59%) and Black (54%) adults say they are worried about becoming infected with the omicron variant, while about a third (35%) of White adults are. Similarly, Hispanic (57%) and Black (43%) adults are much more likely than White (27%) adults to say they are worried about missing work due to an infection.

Two Years into the Pandemic, Most of the Public is Tired and Frustrated

Two years into the pandemic, three quarters of the public say they are both tired (75%) and frustrated (73%) by the state of the pandemic, with more than 7 in 10 Democrats, Republicans and independents reporting these emotions. Fewer people say they are optimistic (42%), angry (40%) or confused (29%). 

In addition, a large majority (77%) also says it is inevitable that most people across the country will get COVID-19 eventually. This includes similar shares among those who are vaccinated (77%) and those who are not (74%), as well as among Democrats (74%), independents (78%) and Republicans (78%). 

Despite widespread reports of vaccinated people testing positive for the omicron variant, a substantial majority (62%) say they believe the vaccines are working because “most vaccinated people who become infected with COVID-19 do not require hospitalization.”

Far fewer (34%) say the vaccines are not working because “some vaccinated people are becoming infected.” The share who see these breakthrough infections as a sign the vaccines are not working has increased slightly since September (26%), driven by shifts among Republicans and unvaccinated adults. 

A third (34%) of the public currently views the pandemic as the country’s biggest problem, slightly more than the share who say rising prices due to inflation (28%) is the biggest problem. Fewer identify climate change (9%), racial inequality (8%) crime (6%) or shortages due to supply-chain issues (5%). 

Partisans rank these problems differently, with three times as many Republicans (44%) as Democrats (13%) saying inflation is the nation’s biggest problem, and more than twice as many Democrats (51%) as Republicans (19%) saying the pandemic is. Roughly equal shares of independents name inflation (30%) and the pandemic (28%) as the nation’s biggest problem.

Other highlights include:

• Nearly a quarter (23%) of adults nationwide say they’ve personally tested positive for COVID-19 at some point during the pandemic, including 8% who say they’ve tested positive in the past month. Among those who tested positive in the past month, 16% (representing 1% of all adults) say they used only an at-home test, indicating the result is unlikely to be captured on official case counts.
• About 1 in 5 adults (19%) say they’ve personally had difficulty in the past few months figuring out whether they needed to isolate or limit their normal activities either after being exposed to COVID-19, receiving a positive test result, or experiencing symptoms. Most (58%) say federal public health authorities’ guidelines for testing and isolation are confusing.
• Most of the public says that COVID-19 vaccinations should be required for people traveling on airplanes internationally (62%) and domestically (55%). Majorities of Democrats and independents support such requirements, though most Republicans do not.
• About 7 in 10 (71%) adults say they worry that restrictions aimed at stopping the spread of omicron will hurt local businesses in their area. Majorities across partisans express worry about the impact of restrictions on local businesses.

Designed and analyzed by public opinion researchers at KFF, the KFF Vaccine Monitor survey was conducted from January 11-23, 2022 among a nationally representative random digit dial telephone sample of 1,536 adults. Interviews were conducted in English and Spanish by landline (165) and cell phone (1,371). 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.

Section 1115 demonstration waivers provide states an avenue to test new approaches in Medicaid and generally reflect changing priorities from one presidential administration to another. The Trump Administration’s Section 1115 waiver policy emphasized work requirements and other eligibility restrictions, payment for institutional behavioral health services, and capped financing. The Biden Administration has signaled a shift in policy to emphasize waivers that expand, rather than restrict, Medicaid coverage and access to care (though still within the limits of budget neutrality). For example, CMS recently rescinded work requirement and premium authorities as part of a limited coverage expansion (at the state’s regular match rate for federal funding) in Georgia’s waiver—an action that the state is challenging in court. Additionally, several states have currently pending waiver requests that may align with these new administrative priorities. This issue brief summarizes waiver priorities and actions under the Biden Administration as well as pending waiver themes and other issues to watch. If the Build Back Better Act (BBBA) fails to pass or is narrowed significantly, Medicaid waivers and other administrative actions may be a key tool for the Biden Administration to advance policy priorities absent legislation.

In November 2021, the Biden Administration signaled that in line with its strategic vision for Medicaid, waivers can foster expanded coverage; improved access, quality, and equity; and value-based care and innovation. Prior to the November 2021 enumeration of these strategic Medicaid priorities, in a January 2021 executive order President Biden identified strengthening Medicaid and increasing health care access as key administrative priorities. The executive order directed relevant agencies to review waiver policies that may reduce coverage under or otherwise undermine Medicaid.

In line with early priorities, CMS began the process to withdraw Section 1115 work requirements and has since issued final withdrawals of these provisions in all states that had approvals. More recently, CMS took steps to withdraw or phase out the inclusion of Medicaid premium requirements above statutory limits. While other components of waivers with withdrawn work requirements or premiums remain intact, CMS has indicated that it may review additional policies. Finally, in April 2021 CMS rescinded the prior administration’s 10-year renewal of the Texas Healthcare Transformation and Quality Improvement Program (THTQIP) waiver because of failure to comply with public notice and comment requirements. However, Texas has challenged and a district court issued a preliminary injunction against the CMS recission. Separately, in July 2021 Texas submitted a new 10-year extension request with the same terms as the January approval. Negotiations between CMS and Texas over specific waiver provisions, including provider reimbursement for uncompensated care, may indicate how these broader policy issues align with current administrative priorities.

Recent waiver approvals and renewals emphasize alignment with broader Biden Administration priorities. One key theme has been approvals of waivers extending the Medicaid postpartum coverage period, highlighting a commitment to improving maternal health and reducing health disparities. In its recent approval of California’s CalAIM demonstration, CMS noted that the waiver advances policy priorities through its person-centered approach, health equity goals, and focus on addressing the health needs of high-need groups including those with behavioral health needs, homeless populations, and justice-involved populations. Similarly, CMS emphasized that its recent renewal of Maryland’s HealthChoice demonstration advances its priority to improve health coverage, access, and equity for Medicaid beneficiaries by expanding programs focused on maternal health, addressing health-related social needs, and enhancing behavioral health services.

CMS decisions on a number of pending waiver requests will inform how the Biden Administration may use waivers to advance stated priorities (Figure 1). In the year since President Biden took office, many states have requested targeted eligibility expansions that would increase coverage and access to care for certain populations, including justice-involved individuals. Though no states have received waiver approval to provide services prior to release from incarceration, CMS recently expressed support for pre-release services in correspondence with California. Recent pending waivers also propose to address health-related social needs and behavioral health needs, areas identified as key priorities by both CMS and states. As federal Medicaid rules prohibit expenditures for most non-medical services, it remains to be seen whether and how the Biden Administration may use demonstration waivers to encourage states to address enrollee social determinants of health.

Health equity is a key goal across pending waiver provisions as well as a priority for the administration both broadly and for Medicaid waivers specifically. In particular, states have highlighted that expanded coverage for high-need populations (including justice-involved individuals, postpartum individuals, and individuals with certain behavioral and/or social needs) and increased focus on social determinants of health will promote health equity. Especially in recent requests to extend and amend long-standing demonstrations, many states have identified equity as a foundational goal underlying all or most provisions. For example, Vermont noted in its extension request that “underlying all [demonstration] goals is Vermont’s commitment to leveraging its 1115 demonstration to advance health equity.” In addition to these overarching goals, some states have also requested specific expenditure authority for initiatives aimed at measuring or incentivizing equity (Figure 1).

Moving forward, Section 1115 waivers may be shaped by additional actions or guidance from CMS, federal legislation, and the future of the COVID-19 pandemic:

• CMS actions and guidance. CMS may continue to review currently approved waiver provisions and could withdraw or decline to renew policies that may reduce Medicaid coverage or access. CMS is also in the process of applying methodology changes to budget neutrality policies that will restrict the ability of states with long-running demonstrations to roll over “unspent” savings and to extend baseline spending assumptions for years without adjustments; it remains to be seen how these policy changes will affect future waiver spending. CMS may also release additional Section 1115 guidance to promote policy priorities and/or to strengthen transparency, public notice, and comment and evaluation requirements.
• Federal legislation. Potential passage of provisions included in the BBBA could affect coverage expansions states have requested in waivers—by requiring 12 months of postpartum coverage and allowing federal money to pay for Medicaid-covered services 30 days prior to release for incarcerated individuals—as well as Medicaid coverage for low-income people in states that have not expanded Medicaid under the Affordable Care Act (ACA), outside of waivers. The BBBA also includes provisions related to Medicaid financing, and benefit changes.
• Future of COVID-19 pandemic. The pandemic continues to challenge state Medicaid programs and to drive their priorities, and these ongoing challenges could hamper states’ capacity to develop and implement new waiver initiatives. At the same time, the pandemic has exacerbated and highlighted issues such as health disparities and health-related social needs; states increasingly identify these areas as top priorities and may address them in future Medicaid waiver requests.

Since the start of the coronavirus pandemic, Congress, states, and both the Trump and Biden Administrations have adopted a number of policies to ease financial pressure on hospitals and other health care providers. The infusion of funds was intended to help alleviate the fiscal impact of revenue loss due to delays in non-urgent care, coupled with new costs associated with COVID-19. With the recent increase in Omicron-related cases, hospitalizations and deaths, this brief describes the main sources of federal funds for health care providers and how those funds have been allocated.  It also describes federal spending for COVID-19 testing, including at-home testing, using the most recent data available (as of September 2021).

The Impact of the Pandemic on Health Care Spending and Providers

The capacity of hospitals and other health care providers to withstand the pressures of the pandemic depends on a variety of factors, including their financial health prior to the pandemic, the impact of the pandemic on revenue and expenses, and how much assistance they received from the federal government. In this section we briefly describe the impact of the pandemic and federal actions to support different types of providers. In the next section, we provide more detail on the various policies enacted by Congress and the Executive Branch over the last two years.

HOSPITAL AND PHYSICIAN SERVICES

Hospital admissions and use of other health care services dropped dramatically during the Spring of 2020, leading to a sharp decline in revenue for hospitals, outpatient centers and physicians. According to the Medicare Payment Advisory Commission (MedPAC), federal coronavirus relief funds and cost reductions allowed some but not all hospitals to remain profitable during the first three quarters of 2020. Further, MedPAC’s preliminary data shows that in 2021, among the six largest hospital systems, operating profits exceeded pre-pandemic levels. However, even though hospital revenues have largely rebounded, total health care spending was still below expected levels through the second quarter of 2021 (based on pre-pandemic spending), according to an analysis from KFF and EPIC Health Research Network

The impact on physicians has varied, according to the MedPAC. Between June and early December of 2020, the volume of total primary care visits (including telehealth) and elective services (e.g., colonoscopies and total knee replacement) were close to or just below the 2019 levels. Based on MedPAC’s analysis, the rapid growth in allowed charges for telehealth services partially offset decline in in-person office visits in early 2020.

SKILLED NURSING FACILITIES

Nursing homes, including skilled nursing facilities, also received federal funds to mitigate the financial effects of the pandemic, although the long-term effects of the pandemic on these facilities remains unclear. According to MedPAC, new federal assistance made available to skilled nursing facilities helped to offset much of their financial losses and costs incurred due to COVID-19, with total margins increasing in 2020 based on preliminary data. However, skilled nursing facility volume remains below pre-pandemic levels and therefore the longer-term effects of lower utilization for some facilities remains uncertain. Additionally, with staffing declining by approximately 10% between February and December 2020, staffing issues and costs could pose a fiscal challenge for skilled nursing facilities into the future.

SAFETY-NET PROVIDERS

Safety-net providers, including those with a high share of Medicaid and uninsured patients, have been at risk of financial strain during the pandemic, according to a MACPAC report. Contributing factors include low operating margins and the pandemic’s disproportionate impact on populations primarily covered by Medicaid, including people of color and those who use long-term services and supports. Providers that tend to serve Medicaid, but not Medicare, patients, such as pediatricians, home and community-based services providers, and behavioral health practitioners, were less likely to have received federal Provider Relief Funds.

Sources of Federal Support for Hospitals and Other Health Care Providers During the Pandemic

Approaching two years into the pandemic, policymakers have provided substantial support for hospitals and other health care providers to compensate for lost revenue and higher expenses associated with the COVID-19 pandemic. The legislative actions are described in the timeline below (Figure 1).

Payments from the Provider Relief Fund and Paycheck Protection Program loans to support hospitals and other health care providers during the pandemic contributed to a substantial increase in federal health care spending in 2020 – a 36% increase in spending in 2020 compared to 6% in 2019, according to National Health Expenditure data. Federal support during the pandemic appears to have stalled the pace of hospital closures, with fewer hospital closures in fiscal years 2020 (25 closures) and 2021 (10 closures) compared to 2019 (46 closures). In particular, many rural hospitals were struggling before and during the pandemic, with 18 rural hospitals closing in 2019 and 19 closing in 2020, while there were just 2 rural hospital closures reported in 2021. According to a Medicaid and CHIP Payment and Access Commission (MACPAC) report, critical access hospitals and other rural hospitals appear to have received more Provider Relief Funds as a share of their operating expenses than other types of hospitals, although it is not clear if the assistance they have received will be sufficient to prevent additional closures that would further impact access. The various funding and other policy actions taken to support providers include:

• Provider Relief Fund: The Provider Relief Fund was initially established under the CARES Act in response to concerns about the impact of the COVID-19 on hospitals and other health care providers across the country. Congress subsequently authorized additional amounts for the Provider Relief Fund in The Paycheck Protection Program and Health Care Enhancement Act and the Consolidated Appropriations Act, 2021 (Figure 1). Of the $178 billion in total amounts authorized for the Fund, HHS allocated $170.9 billion (including $8 billion to support vaccine and therapeutic development and procurement activities (previously known as Operation Warp Speed), leaving $7.1 billion unallocated as of December 2021, according to the Government Accountability Office (GAO) (Figure 2). As of December 2021, $143.5 billion has been disbursed.Initially, the funds were distributed to virtually all Medicare-enrolled health care providers in grants that amounted to at least 2% of their 2018 (or most recent complete tax year) annual total patient revenue to cover lost revenue and unreimbursed costs associated with the pandemic. This approach allowed HHS to disburse funds quickly, but also favored providers with a larger share of revenue from private insurance since private insurers tend to reimburse at higher rates than Medicare and Medicaid. The initial distribution also excluded Medicaid and CHIP providers who were not enrolled in Medicare (38% of all Medicaid/CHIP providers); these providers were unable to apply for federal Provider Relief Funds until June 2020. A MACPAC review of Provider Relief Fund applications submitted as of November 26, 2020 (after the phase three general distribution application deadline closed), found that about 18% of Medicaid and CHIP providers who are not enrolled in Medicare received federal Provider Relief Funds, compared to virtually all Medicare providers, and about 54% of all providers potentially eligible for relief funds. Certain providers—including skilled nursing facilities, safety net hospitals, and hospitals that treated a large number of COVID-19 patients early in the pandemic—were among those that later qualified for additional grants.The Phase 4 distribution of $17 billion announced in September 2021 is based on the change in providers’ operating revenues and expenditures for the period between July 1, 2020 and March 31, 2021. According to HHS, the objective is to reimburse smaller providers for their lost revenues and COVID-19 expenditures at a higher rate than larger providers, because according to HHS, smaller providers are more likely to operate on narrow margins and serve higher-need communities. The Phase 4 distribution also includes bonus payments to providers that billed state Medicaid programs, state CHIPs, and/or Medicare between January 1, 2019 to December 31, 2020. To ensure an equitable distribution, bonus payments will be based on Medicare payment rates, which are generally higher. These bonus payments will account for approximately 25% of Phase 4 funds.

  Of the $17 billion in Phase 4 Provider Relief Funds, HHS has distributed $11 billion, including $9 billion distributed in December 2021 and $2 billion distributed in January 2022. The average payment of the $9 billion distributed in December 2021 ranged from $58,000 for small providers to $1.7 million for large providers. Data on targeted distributions of Phase 4 payments by type of provider are not yet available. According to HHS statements published in an October 2021 GAO report, the remaining unallocated Provider Relief Funds are reserved for future contingencies and emerging needs.

• Additional Funds for Rural Health, Community Health Centers and Other Providers: The American Rescue Plan (ARP) included $8.5 billion for rural health care providers to help cover lost revenue and costs associated with COVID-19 (Figure 1). In November 2021, HHS began distributing $7.5 billion of the $8.5 billion in ARP rural payments to providers. According to HHS, payments to providers varied widely, ranging from $500 to approximately $43 million. Providers or suppliers are eligible for ARP rural payments if they bill Medicare, Medicaid, and/or CHIP, and operate in or serve patients in a rural area. Therefore, eligible providers do not have to be located in a rural area to get an ARP payment. In other words, large health systems in urban centers who serve rural patients are also eligible. Other eligible providers include rural health clinics, critical access hospitals, in-home health, hospice, or long-term care providers. Similar to bonus payments under Phase 4 Provider Relief Funds, ARP rural payments are generally based on Medicare rates to allow an equitable distribution of funds. HHS has not announced the timing for the distribution of the remaining $1 billion of the $8.5 billion appropriated for rural health care providers.The ARP also included $7.6 billion for community health centers, more than $6 billion of which was awarded by HHS in April 2021. The ARP also included $200 million to support infection control and vaccination uptake at skilled nursing facilities.The ARP also included a 10 percentage point increase in the federal matching rate (FMAP) for state spending on Medicaid HCBS from April 1, 2021 through March 31, 2022, an estimated $11 billion nationally, to support home and community based services (HCBS) programs and strengthen the direct care workforce. States may use the enhanced funds for a variety of purposes, including supporting direct care workers, expanding HCBS eligibility and/or services, and improving IT systems. However, a KFF survey of state Medicaid HCBS programs found that 2/3 of responding states (25 out of 38) reported a permanent HCBS provider closure during the pandemic, with most of these states experiencing permanent closure of more than one HCBS provider type.

• Temporary suspension of Medicare automatic payment reductions (sequestration): Congress has provided additional financial protection for hospitals and other health care providers by continuing to waive the automatic 2% reduction in Medicare payments that would be required under budget rules, known as sequestration. COVID-19 relief legislation originally suspended the sequestration payment adjustment of 2% from May 1, 2020 through December 31, 2021.¹  On December 10, 2021, the Protecting Medicare and American Farmers from Sequester Cuts Act, S.610, was enacted into law, which continues to exempt Medicare from sequestration until March 31, 2022 (Figure 1). For the next three months (April 1, 2022 to June 30, 2022), the reduction will be phased in at 1% before resuming to 2% thereafter. However, for fiscal year 2030, payment reductions will be increased to 2.25% during the first 6 months and 3% for the next 6 months of that fiscal year, offsetting the federal budgetary effects of the recent sequestration suspensionsThis recently-enacted law (S. 610) will also delay, until 2023, a separate Medicare sequestration of 4% which would otherwise be triggered in 2022 under statutory Pay-As-You-Go (PAYGO). Specifically, any budgetary effects recorded for the fiscal year 2022 “PAYGO scorecards” will be delayed and added to the amounts for the fiscal year 2023 scorecard. Additionally, S.610 provides a 3% increase in Medicare Physician Fee Schedule (PFS) payments for 2022 in order to mitigate scheduled budget neutral cuts resulting from a 3.75% increase in PFS payments in 2021. These legislative changes provide relief for hospitals and other health care providers serving Medicare patients across-the-board, rather than take a more targeted approach to relieve financially troubled hospitals and other health care providers that were significantly impacted by COVID-19.

• Paycheck Protection Program (PPP) and Other Loans: Many health care providers were eligible for some of the loan programs included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act, including the PPP. Under the PPP for small businesses, loans are forgiven if employers do not lay off workers and meet other criteria. By August of 2020, health care providers received nearly $68 billion of the $525 billion in PPP loans that were distributed in 2020. In 2021, health care providers received another $29 billion of the $278 billion in PPP loans that were distributed that year. The CARES Act also appropriated $454 billion for loans to larger businesses—including hospitals. According to recent preliminary estimates by MedPAC, health care providers have received approximately $100 billion in total PPP loans.
• Medicare Accelerated and Advance Payment Programs: Health care providers that participate in traditional Medicare were eligible for loans through the Medicare Accelerated and Advance Payment Programs, which helps providers facing cash flow disruptions during an emergency. About 80% of the $100 billion in loans went to hospitals. Repayment for the loans was originally set to begin in August of 2020, but Congress delayed the start date for repayments until one year after providers received the loans, which CMS says began as early as March 30, 2021 for those providers and suppliers that received loans on March 30, 2020. Once repayment begins, a portion of the new Medicare claims are reduced to repay the loans (25% during the first 11 months of repayment and 50% during the next six months). CMS is no longer accepting applications for accelerated or advanced payments as they relate to the COVID-19 Public Health Emergency.
• Increase in Medicare COVID-19 inpatient reimbursement: Medicare has increased all inpatient reimbursement for COVID-19 patients by 20% during the public health emergency (PHE), which has been renewed through April 14, 2022. Additionally, under the New COVID-19 Treatments Add-on Payment (NCTAP) policy, eligible providers in the inpatient setting receive additional payments for certain COVID-19 treatments, such as remdesivir or convalescent plasma. In order to incentivize inpatient hospitals to continue providing new COVID-19 treatments beyond the end of the PHE, CMS recently extended the NCTAP for certain eligible technologies through the end of the fiscal year in which the PHE ends. Beneficiaries receiving inpatient care for treatment of COVID-19 are subject to cost sharing (deductible and copayments for extended stays).
• Reimbursement for COVID-19 vaccination administration: Medicare increased its reimbursement for COVID-19 vaccine administration from $17 for an initial dose in a series and $28 for the final dose in a series to approximately $40 per dose. This also applies to booster doses approved by the FDA under the emergency use authorizations. As of June 2021, Medicare also pays an additional $35 per dose for administering the COVID-19 vaccine in the home for certain Medicare patients. Most states have policies in place to increase Medicaid payments for COVID-19 vaccine administration to 100% of the Medicare rate. Medicare and Medicaid beneficiaries are not subject to any cost sharing for the COVID-19 vaccine and administration. For the uninsured and underinsured, a portion of the Provider Relief Funds are being used to reimburse providers for administering COVID-19 vaccines to uninsured or underinsured individuals.
• Medicaid options to support providers: The coronavirus pandemic resulted in financial strain for health care providers who tend to care for a disproportionate share of Medicaid patients. As of July 1, 2021, 41 states increased provider payment rates for a range of provider types via Disaster-Relief State Plan Amendments (SPAs) or other administrative authority, 40 states did so for HCBS waivers specifically using Appendix K, and two states received approval for Section 1115 waivers that increased payment rates for HCBS. States were also able to use retainer payments for certain HCBS providers as well as directed payments through managed care. In a survey of state Medicaid programs, more than two-thirds of responding states (33 of 47) indicated that one or more payment changes made in FY 2021 or FY 2022 were related in whole or in part to COVID-19. Across provider types, the vast majority of COVID-19-related payment changes were rate increases. COVID-19-related payment changes were most commonly associated with nursing facilities (27 states) and HCBS providers (26 states). Additionally, states reported a variety of other FFS payment changes in FY 2021 or planned for FY 2022 in response to COVID-19 including: increasing COVID-19 vaccine reimbursement rates to 100% of the Medicare rate and allowing a broader range of providers to be reimbursed for vaccine administration such as pharmacists, home health agencies, ambulance providers, renal dialysis clinics, and outpatient behavioral health clinics; making retainer payments to HCBS providers and bed hold payments to institutional providers; and making supplemental or add-on payments to certain providers, especially nursing facilities, for COVID-19 patients.
• Other support for safety net providers, underserved populations and testing: There has been additional funding allocated to health centers ($9.6B), reimbursements for testing for the uninsured ($2B) and telehealth support for safety net providers ($300M). In addition, $61.4B has been allocated for broader testing activities, beyond what is described in this brief, including for community-based testing programs and the Indian Health Services. That allocation includes funding from several pieces of legislation, including $4.8 billion from ARP announced by HHS in May 2021. It is unclear if this allocation includes funding for at-home tests being distributed through the United States Postal Service or now eligible for reimbursement by private health insurance. It is not yet clear how the federal government is paying for at-home tests being distributed through USPS and the fiscal impact of providing this coverage.

The Long-Term Impact of the Pandemic Across Providers and Communities Remains Uncertain

When hospitals and other health care providers experienced steep drops in revenue early in the pandemic, Congress stepped in with an infusion of funds to bolster the finances of these providers. Collectively, the infusion of funds and other forms of support have generally maintained or improved providers’ financial performance in 2020.  However, not all providers had equal access to these funds, including providers serving a disproportionate share of Medicaid patients, who were less likely to have received federal Provider Relief Funds or more likely to wait longer to receive these Funds.  With emerging virus variants, including the Omicron variant which has caused rapid increases in COVID-19 infections and hospitalizations, the financial impact of the pandemic across providers and communities still remains unclear. More recently, hospitals have been pressing Congress for additional funds, in light of rising hospital admissions attributable to the Omicron variant. At this time, Congress’ intent on making any statutory changes in response to these concerns is not clear.

1. The CARES Act, H.R.748, originally suspended the sequestration payment adjustment of 2% from May 1, 2020 through December 31, 2020, followed by the Consolidated Appropriations Act, 2021, H.R.133, that extended the suspension period to March 31, 2021, and then H.R. 1868 delayed the reinstatement until December 31, 2021. On December 10, 2021, the Protecting Medicare and American Farmers from Sequester Cuts Act, S.610, was enacted into law, continuing to exempt Medicare from sequestration until March 31, 2022. ↩︎