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.

The data for this analysis comes from the October 2021 KFF COVID-19 Vaccine Monitor. See the initial report for the survey’s full methodological details.The KFF COVID-19 Vaccine Monitor and other surveys have consistently shown a strong relationship between partisan identification and how individuals view and experience the COVID-19 pandemic, on questions ranging from worries about getting infected, to self-reported behaviors like mask-wearing and social distancing, to views on vaccinations. This new analysis shows that although COVID-19 vaccination rates have increased over time with majorities across partisan groups reporting being vaccinated, Republicans make up an increasingly disproportionate share of those who remain unvaccinated and political partisanship is a stronger predictor of whether someone is vaccinated than demographic factors such as age, race, level of education, or insurance status. These results suggest substantial challenges for any efforts to further increase vaccine uptake among U.S. adults, which may also affect acceptance of booster shots and COVID-19 vaccines for children as eligibility expands.

A Large And Growing Share Of Unvaccinated Adults Identify As Republicans Or Lean That Way

Partisanship has been a strong predictor of views on coronavirus from the early days of the pandemic. For example, KFF polling in May 2020 found that Republicans were less likely than Democrats to report wearing masks and practicing social distancing. Early views of the COVID-19 vaccine were similarly divided along party lines with a majority of Republicans saying they would not get vaccinated in September 2020 (compared to Democrats who were more equally divided in whether they would or would not get a COVID-19 vaccine once it became available).

By April 2021, a majority of U.S. adults (56%) self-reported they had already received at least one dose of a COVID-19 vaccine. Among the 43% of adults who said at that time that they had not yet been vaccinated, about four in ten (42%) identified as Republicans or Republican-leaning independents and about one-third (36%) identified as Democrats or leaned that way, while 16% identified as independents who didn’t lean toward either party. The partisan divide between vaccinated and unvaccinated adults became even more evident as larger shares of the population received COVID-19 vaccines. Now, six months later, in October 2021, one-quarter (27%) of U.S. adults say they have not gotten a COVID-19 vaccine, but the unvaccinated population is now disproportionately made up of those who identify as Republican or Republican-leaning, with six in ten (60%) identifying as Republican or Republican-leaning (compared to about four in ten of the U.S. total adult population¹ ) and just one in six (17%) calling themselves Democrats or Democratic-leaning. See Appendix figure 1 for a full demographic profile of unvaccinated adults from April to October 2021.

At the same time that the role of partisanship in predicting vaccination status has increased, our surveys and other KFF research have shown that racial and ethnic gaps in vaccine uptake have narrowed over time. And while other groups such as the uninsured, younger adults, rural residents, and those with lower levels of education continue to be vaccinated at lower rates than their counterparts, multivariate analysis – a statistical model that separates out the influence of these different factors – indicates partisanship stands out as the strongest single identifying predictor of vaccine uptake.²  See Appendix figure 2 for regression analysis results displaying the relative size of the effects of education, race and ethnicity, and partisanship, while holding other variables (such as age, rurality, income, ideology) constant based on average population.

Demographic And Attitudinal Differences Between Vaccinated And Unvaccinated Republicans

While self-identifying as a Republican or leaning Republican is one of the strongest identification predictors of remaining unvaccinated, it is important to note that a majority (59%) of this group (Republican and Republican-leaners) does report receiving at least one dose of a COVID-19 vaccine.

Similar to the overall differences between unvaccinated and vaccinated adults, unvaccinated Republicans are younger and report lower levels of educational attainment than their vaccinated counterparts. Larger shares of unvaccinated Republicans identify as conservative (68% v. 58%) and live in counties where former President Trump received more votes during the 2020 election (65% v. 52%), although this difference is not dramatic.³  Another geographic characteristic – urbanicity –  distinguishes the two groups, with 27% of unvaccinated Republicans living in rural areas compared to 16% of vaccinated Republicans (similar to the urban-rural divide found in the overall vaccination rates).

Exploring attitudinal differences by both partisanship and vaccination status reveals that there are some minor differences between vaccinated and unvaccinated Republicans in how they think about the seriousness of the pandemic, their own personal risk, and how personal choice vs. collective responsibility factors into vaccination decisions. However, vaccinated Republicans’ attitudes look much closer to those of unvaccinated Republicans than they do to vaccinated Democrats, highlighting the strong correlation between these attitudes and partisanship, regardless of vaccination status.⁴ 

For example, vaccinated Republicans are somewhat less likely than unvaccinated Republicans to say the seriousness of the pandemic has been exaggerated in the news (88% vs. 54%), but both groups contrast with vaccinated Democrats, most of whom say the news is generally correct (56%) or underestimates the seriousness of the pandemic (31%). An overwhelming majority of unvaccinated Republicans (96%) and a somewhat smaller but still substantial majority of vaccinated Republicans (73%) say getting vaccinated against COVID-19 is a personal choice, while a large majority of vaccinated Democrats (81%) see it as everyone’s responsibility to protect the health of others. And while vaccinated Republicans are about twice as likely as unvaccinated Republicans to worry that they will personally get sick from COVID-19 (25% vs. 11%), the share that is worried is still substantially less than it is among vaccinated Democrats (46%).

Implications

The increasing role of partisanship in determining individuals’ COVID-19 vaccination status presents a challenge for public health officials and messaging related to any efforts to further increase vaccine uptake among adults. The group that remains to be convinced of the importance of receiving a COVID-19 vaccine is disproportionately represented by those who identify as or lean Republican. Compared to their vaccinated counterparts, these unvaccinated Republicans are distinguished by the voting behavior of their neighbors, their sense that the pandemic is being over-stated, and their lack of a sense of personal risk: factors that may be extremely difficult to overcome in gaining acceptance of COVID-19 vaccines. These findings may also have implications as the vaccine rollout expands to younger children and the CDC recommends booster shots for some adult populations. With most vaccinated Republicans saying they’re not worried about getting sick and 38% of fully vaccinated Republicans saying they do not plan to get a booster shot when eligible, it seems likely that partisanship will continue to play a role in the vaccine rollout beyond the initial effort to vaccinate the adult population.

1. The share of Republicans and Republican-leaning independents in the most recent KFF COVID-19 Vaccine Monitor is at 41% of the U.S. adult population, which is similar to the share reported by Gallup and Pew Research Center during the same time period. ↩︎
2. In addition to the analysis included in this research brief, we also used ordinary least squares regression models (OLS) and logit regressions with each cross-sectional survey predicting being unvaccinated to produce predicted probabilities. The independent variables include gender, race/ethnicity, age, education, partisanship, income, urbanicity, LGBT identity, ideology, health care worker status, and health insurance coverage when available in the month’s survey. Predicted probabilities from the logit regression models from the September data is displayed in Appendix figure 2. ↩︎
3. This is consistent with recent academic research that suggests that views of all COVID-19 related health behaviors, including vaccine intentions, is correlated with Trump favorability. Previous KFF analysis found a similar vaccination gap between counties that voted for President Biden compared to President Trump ↩︎
4. The sample size of unvaccinated Democrats is too small for analysis. ↩︎

Introduction

The U.S. Congress, the legislative body of the U.S. government (USG), plays an important role in determining and shaping the government’s global health policy and programs. Although only one of many USG entities involved in global health, its engagement has been particularly notable over the last 20 years, which have been marked by unprecedented bipartisan support for U.S. global health efforts and resulted in the authorization of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. government’s coordinated response to global HIV and the largest program focused on a single global health issue in the world, as well as the appropriation of significantly increased funding. It has also played a key role in the U.S. response to recent global health emergencies, including Ebola, Zika, and COVID-19 as well as increasing U.S. support for global health security and pandemic preparedness and response efforts. Indeed, Congress fulfills a key role in U.S. global health policy by setting the broad parameters and priorities of U.S. global health programs, determining their funding levels, and overseeing the implementation and effectiveness of supported efforts. Its activities in this area are complemented and influenced to varying degrees by those of numerous stakeholder groups and individuals that, while not examined in this primer, are key actors in the policymaking process. Such stakeholders include: advocates, the private sector, think tanks, academic institutions, religious communities and organizations, people directly affected by global health issues (such as people living with HIV), and others.

To help shed light on Congress’ role in global health, this primer provides an overview of its engagement in this area, aiming to provide a basic framework with which congressional efforts may be understood. First, it examines the structure of Congress and its role and key activities in global health, which range from authorizing the creation of and providing funding for U.S. global health programs to engaging in program oversight and confirming presidential appointees to lead these efforts. It then illustrates these by examining selected legislative activities for two global health examples: the creation and evolution of PEPFAR and the 2014/2015 Ebola outbreak in West Africa. Finally, it discusses opportunities and challenges related to congressional engagement in global health going forward.

Structure

Congressional engagement in global health is carried out by the two chambers of Congress – the U.S. House of Representatives and the U.S. Senate – and their members, committees, and caucuses. This work is supported by a cadre of congressional staff as well as legislative branch agencies and offices (e.g., the Congressional Budget Office (CBO), the Government Accountability Office (GAO), and the Congressional Research Service (CRS)).

Chambers

The U.S. House of Representatives (the House) and the U.S. Senate (the Senate) debate and vote on legislation, including legislation related to global health, among other activities. The House is the larger body, whose members represent 435 congressional districts, which are distributed across states based on population during the most recent census; House members are up for re-election every two years. The Senate has 100 members, two from each state, who are up for re-election every six years.

Members

Each chamber is made up of individuals who have been elected to serve as members of Congress for certain periods of time (see Box 1). Members’ engagement in global health may include a variety of actions, such as: sending official correspondence (e.g., to the Executive Branch or to congressional colleagues individually or via “Dear Colleague” letters¹ ), speaking publicly and/or privately, participating in congressional delegations to the field, issuing press releases, introducing or co-sponsoring legislation, and, most importantly, voting on legislation. (It is important to keep in mind that legislation may be a product of negotiations with the Executive Branch.)

Committees

Within each chamber, the work of Congress is generally performed by smaller groups of members, known as committees. Committees examine issues under their jurisdiction and may also consider and vote on legislation. Passage of a piece of legislation by a committee allows it to be brought before the chamber as a whole. Currently, the Senate has 16 standing (permanent) committees and four select and special committees, which may be permanent or temporary and typically “examine emerging issues that do not fit clearly within existing standing committee jurisdictions or cut across jurisdictional boundaries.” The House has 20 standing committees and five select committees.³  Additionally, there are four joint committees of the House and Senate, which are permanent, bicameral entities that do not consider legislation but rather carry out studies and certain administrative functions for Congress. Although the organization of committees in each chamber is rooted in a 1946 law that originally laid out similar committees in each chamber, the committee structure has evolved over time, leading to more variation across committees and chambers.⁴ 

There are more than ten congressional committees whose work relates to global health,⁵  although a smaller subset of six committees has primary jurisdiction over most global health programs and funding. These six are: the House Committee on Foreign Affairs (HFAC), the Senate Committee on Foreign Relations (SFRC), the House Committee on Energy and Commerce (E&C Committee), the Senate Committee on Health, Education, Labor, and Pensions (HELP Committee); and the House and Senate Committees on Appropriations (Approps. Committees). See Table 2 for an overview of jurisdiction by committee. Also see Appendix A for an overview of key committees and subcommittees’ leadership as well as a listing of members serving on these during the 117th Congress.

Caucuses

Members of Congress may also establish formal or informal groups of members, known as caucuses, focused on specific topics.⁶  Caucuses may be bipartisan (drawing their membership from both Democrats and Republicans) and bicameral (including members from both chambers), but they do not have to be. Among current caucuses, there are nearly 10 related to global health, including: the Congressional Global Health Caucus, the Congressional HIV/AIDS Caucus, the Tuberculosis Elimination Caucus, the Congressional Caucus on Malaria and Neglected Tropical Diseases, the Senate Caucus on Malaria and Neglected Tropical Diseases, the House Hunger Caucus, the Senate Hunger Caucus, and the COVID-19 Global Vaccination Caucus. See Appendix B for a listing of global health-related caucuses and their leadership during the 117th Congress.

Role and Key Activities

Congress is responsible for determining the broad outlines and priorities of U.S. global health efforts, providing funding for USG agencies and departments to carry them out, and overseeing the conduct and impact of these efforts. Congress fulfills this role through an array of activities, which generally fall under two broad umbrellas: introducing, considering, and passing legislation and carrying out oversight activities, including confirming presidential appointees to key USG global health positions.

Legislation

Legislation considered by Congress may be either a resolution or a bill, each of which serves different functions.⁷  These types of legislation are described below, and Table 1 provides several examples of global health-related legislation.

Resolutions

Resolutions often recognize or commemorate a person, day, or issue or express a position on an issue but generally do not become law (i.e., most are non-binding), though there are some that may be more similar to bills. For example, a resolution “recognizing the importance of sustained United States leadership to accelerating global progress against maternal and child malnutrition and supporting the commitment of the United States Agency for International Development to reducing global malnutrition through the Multi-Sectoral Nutrition Strategy” was passed by the Senate in 2020, as was a similar resolution in the House.⁸ 

Resolutions are generally one of three types: a simple resolution, a concurrent resolution, and a joint resolution. Simple and concurrent resolutions are used most often with regard to specific global health issues and have similar functions: A simple resolution usually expresses the sentiments of the chamber of Congress that voted for its passage, while a concurrent resolution also serves this function (as well as sometimes being used for congressional administrative matters) but is voted upon by both chambers. For example, the Senate passed a simple resolution on “supporting the goal and ideals of World Polio Day and commending the international community and others for their effort to prevent and eradicate polio” in 2014, while the House and the Senate passed a concurrent resolution to address a matter affecting the operation of both chambers, specifically correcting the enrollment (final agreed form) of a bill addressing U.S. global HIV, TB, and malaria activities.⁹  On the other hand, unlike the other two types, a joint resolution may have the force of law if it passes both chambers and is subsequently submitted to and signed by the President. In such cases, it is more similar to a bill. Joint resolutions, however, differ from bills in the ways in which they are used and with regard to the content they generally address: joint resolutions are often used to propose changes to current law that are relatively minor, temporary, or short-term in nature, and are also sometimes used to create temporary bodies or commissions. In general, joint resolutions are used less often with specific regard to global health and, rather, are used to address broader matters (like budget matters) that may impact global health.

Bills

Bills, which may become law if they pass both chambers and are subsequently submitted to and signed by the President, usually either function to authorize U.S. funding, programs, and activities or to appropriate U.S. funding for such programs and activities (see below).

Authorization Bills

An authorization bill may lay out congressional priorities for global health programs, including approaches/strategies, focus countries, target groups (vulnerable populations), and targets (keeping in mind that legislation may be the result of negotiations with the Executive Branch). It may also broadly create and/or modify the policies and organization of USG global health efforts and drive support for the creation/growth of new global health organizations internationally. For example, the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Leadership Act) authorized and institutionalized the President’s Emergency Plan for AIDS Relief (PEPFAR) program by: authorizing the expansion of U.S. global efforts to address HIV, TB, and malaria in low- and middle-income countries through U.S. bilateral assistance as well as U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund, which is an independent, multilateral financing entity designed to raise significant new resources to combat HIV, TB, and malaria in low- and middle-income countries); outlining PEPFAR’s organizational structure as a coordinated, whole-of-government response to global HIV, including establishing the position of the U.S. Global AIDS Coordinator; and defining the key priorities and policies of the program. Later, the Tom Lantos and Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2008 (Lantos-Hyde Act) reauthorized these efforts for five more years and redefined the priorities and policies of the PEPFAR program. Additionally, as sometimes happens with legislation, the Act also included provisions (such as codifying the position of the U.S. Global Malaria Coordinator and requiring a five-year global malaria strategy) that had appeared in other proposed legislation.¹³  See the KFF brief on PEPFAR reauthorization.

An authorization bill may also define the period during which such activities may be operated and provide guidance on the amount of funding to be provided. Still, while specifying an authorized level of funding in an authorization bill may be indicative of congressional intent to appropriate funding at certain levels, funding is actually appropriated through appropriations bills, and Congress is not required to appropriate the level of funding that is authorized for a discretionary program (see Box 2 and further discussion below). In some instances, Congress may appropriate more funding than authorized (see Box 3), while in others, it may appropriate less. For example, in the Leadership Act of 2003, Congress authorized up to $15 billion for U.S. global HIV, TB, and malaria efforts, including bilateral assistance as well as U.S. contributions to the Global Fund, from FY 2004 through FY 2008, but ultimately, it appropriated nearly $19.8 billion for these efforts during that period.¹⁴   On the other hand, in the Lantos-Hyde Act of 2008, Congress authorized up to $48 billion for these same efforts from FY 2009 through FY 2013 but, ultimately, appropriated just under $37.2 billion for them during that period.¹⁵ 

Appropriations Bills

An appropriations bill provides funding for specific programs and activities. Because support for all U.S. global health programs is considered discretionary (versus direct – or mandatory – funding), funding is typically determined (appropriated) on an annual basis by Congress; see Box 2 for more information on these two different kinds of federal spending.

Over time, particularly in the last decade, Congress has increased levels of funding for global health, making the U.S. government the largest donor to global health in the world. However, since FY 2010, non-emergency U.S. funding for global health has remained relatively flat (see Figure 1).¹⁷  In recent years, it has provided higher levels than requested in the President’s Budget for regular appropriations, and it has also supported supplemental appropriations for emergency humanitarian, health, and pandemic responses.

• Regular appropriations. Each year, bills referred to as “regular appropriations bills” outline funding for government programs and activities, including for U.S. global health activities, within specified USG agencies and departments for a single fiscal year. For example, the Department of State, Foreign Operations, & Related Programs Appropriations Act (SFOPS bill) provides funding for USAID, the Department of State, and the Millennium Challenge Corporation (MCC), while the Departments of Labor, Health and Human Services, and Education, & Related Agencies Appropriations Act (Labor/HHS bill) provides funding for CDC, NIH, and FDA, among others. In some years, Congress may pass some or all regular appropriations bills individually or as part of a larger bill that bundles them together during vote consideration (an “omnibus” bill). In others, it may not pass some or all of these bills, instead opting to pass a “continuing resolution” that, generally, maintains U.S. funding at the prior fiscal year’s levels.Typically, at least five regular appropriations bills include components of global health activities carried out by more than 15 USG entities; these bills are the SFOPS bill; Labor/HHS bill; Department of Defense Appropriations Act; Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act; and Financial Services and General Government Appropriations Act.¹⁹ 
• Supplemental appropriations. Less frequently, a bill referred to as a “supplemental appropriations bill” may provide additional funding to agencies to support emergency activities or other urgent needs that must be filled before the passage of the next fiscal year’s regular appropriations bills.²⁰  For example, supplemental appropriations that included global health components supported funding for the USG’s response to unforeseen events, crises, and humanitarian disasters, such as the 2009 H1N1 pandemic, the 2010 Haiti earthquake, the 2014-2015 Ebola outbreak in West Africa, the 2015-2016 Zika outbreak, and the ongoing COVID-19 pandemic.²¹ 

Key Provisions and Reports

While these two kinds of bills – authorization and appropriations bills – are intended to be interrelated as part of a two-step process where each type fulfills a different function, Congress has increasingly used these bills for similar purposes (with the caveat that appropriations bills remain the only legislative vehicle for providing funding).

As a consequence, Congress now may (and often does) include provisions in both authorization and appropriations legislation that provide specific guidance or requirements for how funding be spent and/or how USG global health programs be implemented. These provisions may include spending directives as well as other legislative requirements and restrictions, which are discussed below.

• Spending directives. These may relate to certain bilateral global health programs as well as U.S. contributions to certain multilateral/international organizations. For example, in the Consolidated Appropriations Act of 2021 (which included the SFOPS bill), Congress provided guidance on the amount of funding to be directed to the U.S. contribution to the U.N. Population Fund (UNFPA) by stating that $32.5 million should be made available for this purpose.²² 
• Other legislative requirements and restrictions. These may range from requiring regular reporting to Congress on global health efforts to the development of five-year strategies on a specific global health issue to the conduct of programs to accordance with specific guidelines. For example, Congress requires USG global family planning/reproductive health (FP/RH) funding only be used to support organizations that “offer, either directly or through referral to, or information about access to, a broad range of family planning methods and services” through a provision known as the DeConcini Amendment in the SFOPS bill each year.²³ 

Additionally, congressional committees with jurisdiction over global health-related legislation may also issue reports on legislation. While these reports are not binding and do not have the force of law, they may offer more specific guidance to the Executive and Judicial Branches (and other audiences) about how Congress would like to see a piece of legislation interpreted and more specifics about certain aspects of the legislation.²⁴ 

Oversight

Congressional oversight of government programs, including for global health, is generally the purview of the committee or committees with responsibility for reviewing the activities and performance of departments and agencies under their jurisdiction (see Table 2 for key committees’ jurisdiction related to global health). Their oversight activities may include the following:

• Holding hearings. Hearings can draw public and congressional attention to recent developments and issues as well as inform the legislative process. For example, in the context of global health, Congress held several hearings on malaria in 2004 and 2005 that drew attention to and questioned key aspects of USAID’s approach to addressing malaria, such as the small proportion of U.S. malaria support devoted to buying and distributing commodities (e.g., bed nets and antimalarial drugs) as well as its overall impact and effectiveness.²⁵  Later, in 2006, another congressional hearing reviewed changes that had been made to the USAID malaria program in 2005, when (among other things) the agency began to operationalize the newly-created President’s Malaria Initiative (PMI), which President Bush had launched in 2005 to expand U.S. global malaria efforts, and direct more funding to commodities.²⁶ 
• Reviewing legislatively-mandated reports to Congress. This provides an opportunity for members and their staff to evaluate the status of efforts relative to legislative benchmarks. For example, the Executive Branch submits annual reports to Congress on the PEPFAR program and periodic reports to Congress on USAID health research & development (R&D) activities, among other things.²⁷ 
• Approving changes to program funding allocations through the review of congressional notifications (known as CNs) from USG agencies. CNs provide some flexibility to agencies when circumstances necessitate changes to how funding is to be spent after Congress has already appropriated funding; the CN process provides Congress with a chance to review, evaluate, and approve such changes with regard to certain funding. This could include, for example, a CN requesting a change in the amount of funding planned to support activities related to a particular global health area in a specific country.²⁸ 
• Reviewing the rules, regulations, and policies promulgated by departments and agencies to implement laws, policies, and congressional recommendations.²⁹  Such review may help to influence the final form these implementing mechanisms take. Congress may also exercise its authority to disapprove rules and regulations, though this authority “has been little used by Congress.”³⁰ 
• Issuing congressional reports. Congressional committees may issue reports on issues under their jurisdiction that they are investigating.³¹  For example, in 2006, the then-House Committee on Government Reform issued a committee report based on a study conducted by its Subcommittee on National Security, Emerging Threats, and International Relations, which examined strengthening disease surveillance. Though the report’s findings and recommendations focused on improving U.S. domestic disease surveillance in order to detect global threats, it also discussed global disease outbreaks and select USG global disease surveillance efforts, such as the Department of Defense’s Global Emerging Infections Surveillance and Response System (GEIS).³² 
• Approving treaties proposed and negotiated by the Executive Branch. Before the U.S. may officially accede to a treaty, the President must submit the treaty to the Senate for its advice and consent; with the Senate’s approval, the President may then proceed with ratifying the treaty.³³  For example, the Senate approved the Food Aid Convention (FAC, a treaty negotiated in 1999 that aimed to “ensure that the international community can respond to emergency food situations, as well as ongoing food needs in developing nations” and that also “promotes food security, especially for vulnerable populations”³⁴ ), allowing the U.S. to ratify the treaty in 2001. More recently, the Senate approved the FAC’s successor, the Food Assistance Convention (the FAC expired in 2003), allowing the U.S. to ratify the treaty in 2012, the same year in which it was negotiated.³⁵ 
• Confirming presidential appointees. A function reserved to the Senate, providing advice and consent on the nominations of individuals for certain key global health-related positions within the USG allows the Senate to review and question each nominated individual’s priorities for and approach to their position. See below for further discussion.

Confirmation of Key USG Officials

As required by the U.S. Constitution and law, people appointed by the president to certain positions within the USG may only be confirmed with the advice and consent of the Senate.³⁶  With regard to global health, a number of positions with federal departments and agencies require such confirmation. Some of these positions are mainly or entirely focused on global health (e.g., the U.S. Global AIDS Coordinator, who holds the diplomatic rank of Ambassador-at-Large, at the State Department; the Assistant Administrator for the Bureau for Global Health at USAID), while other positions are generally focused on global development but include global health in their purview (e.g., the Administrator of USAID). Still other positions requiring Senate confirmation have a broader portfolio that includes global health among many other issues (e.g., the Secretary of Health and Human Services).

The confirmation process, which involves both the committee with jurisdiction and the Senate as a whole, proceeds at varying speeds, depending on the nominee, the position for which they are nominated, questions or concerns raised about their nomination by a Senator(s) (if any), and the broader political context and timing of the nomination. Generally, the relevant committee is responsible for gathering information about a nominee, and it may or may not hold a hearing related to the nomination before deciding whether or not to recommend the nominee to the full Senate for a vote.³⁷  (See also the PEPFAR example below.)

Member Engagement

Additionally, members of Congress may individually weigh in on the conduct of USG global health efforts in various ways (e.g., by drafting letters to USG officials about global health issues/programs, as 98 members did in 2009 when they sent a letter to President Obama in which they urged him to request at least $1.75 billion for the U.S. contribution to the Global Fund as part of his FY 2011 budget request³⁸ ), and congressional member and staff delegations may visit sites of USG global health efforts during official visits overseas.

Examples of Congressional Engagement

PEPFAR

Though the history of congressional engagement in global HIV spans several decades, Congress has become substantially more involved in responding to the epidemic over the past 20 years. It has employed a variety of legislative tools and activities – from legislation to hearings to caucuses – in its efforts to shape and reshape the USG response to global HIV, leading up to and through PEPFAR.

Legislation

While PEPFAR is widely seen as a signature initiative of President George W. Bush, some members of Congress had already begun laying legislative groundwork for an expanded U.S. global HIV effort and crafting legislation that served as an early blueprint for PEPFAR. Just four months after President Bush announced his intention to create PEPFAR during his 2003 State of the Union Address, Congress passed legislation authorizing the program at up to $15 billion in funding for U.S. global HIV, TB, and malaria efforts over five years; since then, the program has been reauthorized three times (see Table 1). PEPFAR illustrates how global health endeavors evolve over time, requiring Congress, as well as the Administration and non-government stakeholders, to navigate conflicting approaches, disparate priorities, and changing budget environments; this is reflected, for example, in the evolving content of PEPFAR’s authorizing legislation over time, as well as PEPFAR’s appropriations history. Each authorization has addressed different aspects of policy and programming, with Congress spelling out spending directives as well as other requirements and restrictions for PEPFAR activities through these pieces of legislation. For example, the Leadership Act of 2003 included a spending directive that required not less than 10% of HIV funding be spent on orphans and other children affected by or vulnerable to HIV/AIDS (a provision which remains in force today), and the Lantos-Hyde Act of 2008 required additional PEPFAR reporting to Congress, including a report by the Comptroller General about the coordination of USG global HIV efforts and the impact of PEPFAR funding and programs on other USG global health programming.³⁹  In addition, whereas Congress appropriated substantially more funding in PEPFAR’s first five year period than the $15 billion authorized for the program, it appropriated significantly less than that authorized in its next five years and has essentially flat-funded the program since, reflecting a dramatically changed budget context.

Oversight

Congressional oversight of PEPFAR takes many forms, including: public hearings; review of reports to Congress that describe, for example, how appropriated funding has been spent and documenting progress toward congressionally-mandated targets for PEPFAR efforts; the creation of at least two congressional caucuses focused specifically on global HIV (along with other caucuses addressing broader global health issues that have also worked to address HIV); congressional participation on delegations to the field; and the engagement of individual members in a variety of activities. With regard to the latter, the substantial engagement of a number of members of Congress has, historically, been important in advancing not only related legislation but also in both buttressing as well as challenging USG policy, programming, and goals related to HIV: Over the years, a number of members have written letters to leaders in the Executive Branch about PEPFAR activities, spoken on the floor of the House and Senate at length about HIV, and engaged with the HIV community and, more broadly, the global health community through a variety of fora.

Additionally, of particular importance in the context of PEPFAR oversight is the Senate confirmation of the leader of PEPFAR, known as the U.S. Global AIDS Coordinator. A novel approach to coordinating U.S. global health efforts related to a single issue at the time of the position’s creation, the Coordinator oversees U.S. global HIV efforts across USG departments and agencies but is based at the U.S. Department of State; however, the Coordinator exercises significant authority over HIV funds across USG agencies, which remains a unique attribute of the position relative to leaders of other USG disease-specific programs. While the person who will lead PEPFAR is appointed by the president, the position is among those that must be confirmed with the advice and consent of the Senate.

West Africa Ebola Outbreak

By the latter half of 2014, congressional attention to the then-rapidly-expanding outbreak of Ebola virus disease in West Africa grew quickly, and the ensuing flurry of congressional activity provides a snapshot of the varied ways in which Congress may engage with a global health issue. The Ebola outbreak began to garner more attention in the U.S., and specifically on Capitol Hill, after the infection of two American health workers overseas who were working with Ebola-infected patients was announced in July 2014. At about the same time, the non-governmental organization Medicins San Frontieres (MSF) issued a global call for help, stating that “Ebola is no longer a public health issue limited to Guinea [the country where the outbreak began]. It is affecting the whole of West Africa.”⁴⁰ 

In the years following that, congressional efforts were wide-ranging and included public hearings, legislation (both binding and non-binding), and member engagement on the issue (e.g., several members called for more information about and increased USG actions in response to the outbreak). Some key activities are described below.

Legislation

Several pieces of legislation related to the Ebola outbreak, including non-binding resolutions and appropriations bills, were passed by Congress (or in the case of resolutions, by one or more chamber of Congress). For example, in September 2014, the Senate passed a resolution that recognized the outbreak as a “severe threat” to populations, government, and economies across Africa and potentially beyond, and also that month, Congress passed a continuing appropriations resolution that provided continued funding for USG agency efforts, including greater funding for accelerating Ebola research and development activities as well as the USG response to the outbreak.⁴¹  Subsequently, in November 2014, President Obama requested $6.18 billion in emergency funding for Ebola.⁴²  Then-Chairwoman of the Senate Appropriations Committee, Senator Barbara A. Mikulski (D-MD) stated at that time, “Ebola, in my mind, meets the criteria for emergency spending. It’s sudden. It’s urgent. It’s unforeseen. And it’s temporary.”⁴³  Shortly thereafter, in December 2014, Congress passed an omnibus appropriations bill that included $5.4 billion in emergency funding for Ebola response and recovery efforts, of which $3.7 billion was specifically designated for international efforts.⁴⁴  Attention then turned to oversight of this funding, specifically to how agencies planned to spend the funds provided by Congress. As with other USG global health funding, Ebola funding was governed by various spending directives and other congressional guidance, and agencies had to seek congressional approval (through CNs) as their spending plans changed over time.⁴⁵ 

Oversight

Congressional efforts to oversee the U.S. government’s response to the West Africa Ebola outbreak were multifaceted and included public hearings, the approval of changes in planned funding allocations across certain agencies, and the engagement of individual members as well as caucuses in a variety of activities. In 2014 alone, five congressional committees (or their subcommittees) convened eight public hearings on the Ebola outbreak, beginning in early August 2014; see Table 3. As the outbreak grew and attention to it increased both within policy circles and in the U.S. more broadly, congressional and public attendance at hearings steadily increased.⁴⁶  Congress also authorized the repurposing of funds by agencies to respond to the Ebola outbreak, which was accomplished through the CN process when, for example, DoD requested and received congressional approval to spend up to $750 million in previously-appropriated but leftover war funds on its Ebola outbreak response.⁴⁷  With regard to individual member engagement, various members spoke about Ebola in floor speeches on the House and Senate floors, discussed the need for greater USG resources and an intensified organizational response to the outbreak, and participated in public events that focused on Ebola through caucuses and other organizations.⁴⁸ 

Looking Ahead

Congressional engagement has a significant impact on the USG's role in global health. Over the last 20 years alone, bipartisan congressional support for global health has led to expanded U.S. efforts to address global HIV, TB, and malaria, in particular (among other things, such as global health security), including significantly increased funding, and also respond to global health emergencies, such as pandemic influenza, Ebola, Zika, and COVID-19. Congress, through the array of activities carried out by its congressional committees, caucuses, and individual members, has played and will continue to play an important role in shaping and overseeing U.S. global health efforts. Key issues and opportunities going forward include:

• educating new and continuing members and staff about USG global health efforts, recent developments, and the role of Congress;
• maintaining and strengthening bipartisan support for USG global health programs and funding, given the shifting make-up of Congress over time and in light of current fiscal constraints;
• assessing USG support for multilateral engagement, innovative financing mechanisms, and public-private partnerships, given their role in leveraging USG global health funding and resources;
• ensuring that the legislative framework for USG global health programs is responsive to an evolving global health environment as well as U.S. interests and considerations; and
• providing ongoing oversight, particularly as USG global health efforts are increasingly transitioned to partner countries (i.e., as country ownership is heightened) in order to ensure transparency, accountability, and sustainability in these activities.

Appendix A: Key Congressional Committees and Subcommittees Related to Global Health

Appendix B: Key Congressional Caucuses Related to Global Health

1. Congressional Research Service (CRS), “Dear Colleague” Letters: Current Practices, RL34636, Nov. 25, 2008. ↩︎
2. Five non-voting Delegates and one non-voting Resident Commissioner also serve in Congress but are not included in this total. They represent the District of Columbia, Guam, the U.S. Virgin Islands, American Samoa, the Northern Mariana Islands, and Puerto Rico in Congress. ↩︎
3. CRS, Committee Types and Roles, Report 98-241, Nov. 10, 2014; U.S. Senate, “Committees,” webpage, https://www.senate.gov/committees/index.htm; U.S. House of Representatives, “Committees,” webpage, http://www.house.gov/committees/; Library of Congress, “Committees of the U.S. Congress,” webpage, https://www.congress.gov/committees, accessed Oct. 26, 2021. ↩︎
4. CRS, Committee Types and Roles, Report 98-241, Nov. 10, 2014. ↩︎
5. KFF, The U.S. Government Engagement in Global Health: A Primer. ↩︎
6. U.S. Senate, “Committees,” webpage, https://www.senate.gov/committees/index.htm; U.S. House of Representations Committee on House Administration, “CMO/CSO Registration Form,” webpage, https://cha.house.gov/member-services/congressional-member-and-staff-organizations/cmocso-registration-form#cmo. ↩︎
7. CRS, Bills and Resolutions: Examples of How Each Kind Is Used, Report 98-706. ↩︎
8. U.S. Congress, S.Res.260, 116th Congress, 2020; U.S. Congress, H.Res.189, 116th Congress, 2020. ↩︎
9. U.S. Congress: S.Res.270, 113th Congress, 2014; S.Con.Res.46 - A concurrent resolution to correct the enrollment of H.R. 1298, 108th Congress, 2003; CRS, Enrollment of Legislation: Relevant Congressional Procedures, RL34480, Oct. 14, 2015. ↩︎
10. U.S. Congress: S.Res.225, 109th Congress, 2005; H.Con.Res.46, 108th Congress, 2003; S.J.Res.111, 98th Congress, 1983; H.J.Res.124, 113th Congress, 2014. ↩︎
11. KFF, The U.S. Government Engagement in Global Health: A Primer; U.S. Congress: Global AIDS and Tuberculosis Relief Act of 2000 (P.L. 106-264); United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (P.L. 108-25), Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293), PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56), and PEPFAR Extension Act of 2018 (P.L. 115-305. ↩︎
12. Department of Defense Appropriations Act of 1986 (note: effectively authorized the creation of the Military HIV Research Program (MHRP)); Department of Defense Appropriations Act of 2001 (note: effectively authorized the creation of the Defense HIV/AIDS Prevention Program (DHAPP)); KFF, Health in Haiti and the U.S. Government Involvement, fact sheet, Feb. 2010; CRS, FY2010 Supplemental for Wars, Disaster Assistance, Haiti Relief, and Other Programs, Aug. 6, 2010. ↩︎
13. These two provisions, which were incorporated into the Lantos-Hyde Act, appeared in  the Elimination of Neglected Diseases Act of 2005 (S. 950, not enacted). CRS, The President’s Malaria Initiative and Other U.S. Global Efforts to Combat Malaria, R40494, April 6, 2009. ↩︎
14. U.S. Congress, United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (P.L. 108-25); CRS, PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, and Malaria Programs and Funding, RL34569, Jan. 29, 2009. ↩︎
15. U.S. Congress, Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293); KFF analysis of data from KFF, U.S. Global Health Budget Tracker, downloaded Nov. 11, 2015. ↩︎
16. CRS, Introduction to the Federal Budget Process, Report 98-721. ↩︎
17. KFF, The U.S. Government and Global Health, fact sheet. ↩︎
18. CRS, State, Foreign Operations Appropriations: A Guide to Component Accounts, R40482, Jan. 13, 2015. ↩︎
19. KFF: Budget Tracker: Status of U.S. Funding for Key Global Health Accounts,” tool; The U.S. Government and Global Health, fact sheet. ↩︎
20. U.S. Senate, “Glossary: Supplemental Appropriation,” webpage, https://www.senate.gov/about/glossary.htm#S. ↩︎
21. U.S. Congress: Supplemental Appropriations Act, 2009 (P.L. 111-32); Supplemental Appropriations Act, 2010 (P.L. 111-212); Consolidated and Further Continuing Appropriations Act, 2015 (P.L. 113-235); Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response and Preparedness Act (P.L. 114-223); Coronavirus Preparedness and Response Supplemental Appropriations Act (P.L. 116-123); Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136); Coronavirus Response and Relief Supplemental Appropriations Act, 2021 (P.L. 116-260); American Rescue Plan Act of 2021 (P.L. 117-2). See also KFF, Global Funding Across U.S. COVID-19 Supplemental Funding Bills. ↩︎
22. U.S. Congress, Consolidated Appropriations Act, 2021 (P.L. 116-260). ↩︎
23. KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
24. These may also be referred to as House, Senate, or Conference Reports. U.S. Government Publishing Office, “Congressional Reports,” webpage, https://www.govinfo.gov/app/collection/CRPT/. ↩︎
25. CRS, The President’s Malaria Initiative and Other U.S. Global Efforts to Combat Malaria, R40494, April 6, 2009. ↩︎
26. CRS, The President’s Malaria Initiative and Other U.S. Global Efforts to Combat Malaria, R40494, April 6, 2009. For more information on U.S. global malaria efforts, including PMI, see KFF, The President’s Malaria Initiative and Other U.S. Government Global Malaria Efforts, fact sheet. ↩︎
27. The most recent iterations of these reports are: Department of State/Office of the Global AIDS Coordinator, PEPFAR 2021 Annual Report to Congress, 2021; USAID, USAID Report to Congress on Health-Related Research and Development for Fiscal Year 2019, 2020. ↩︎
28. The requirements for congressional notification vary based on the type of request, the funding involved, its governing legislation, the committee of jurisdiction, and the requesting agency/department. When congressional notification (CN) is required, a member who has concerns or additional questions about a congressional notification’s reprogramming or transfer request may place a hold on approval of the CN through the committee, which effectively instructs the requesting agency to take no further action with regard to the specified funds until further information is provided to the committee and the hold is lifted. Although such holds do not have the force of law, the use of holds is part of an informal “understanding between congressional committees and agencies under their jurisdiction.” See CRS, The Executive Budget Process: An Overview, R42633, July 27, 2012, and CRS, The Congressional Appropriations Process: An Introduction, R42388, Nov. 14, 2014, for more information about the congressional notification process as well as the reallocation of budget authority through transfers (“a shift of budget resources from one appropriations account to another”) and reprogramming (“a shift of budgetary resources from one project or purpose to another within an appropriations account”). ↩︎
29. CRS: Counting Regulations: An Overview of Rulemaking, Types of Federal Regulations, and Pages in the Federal Register, R43056, July 14, 2015; Congressional Review of Agency Rulemaking: An Update and Assessment of The Congressional Review Act after a Decade, RL30116, updated May 8, 2008; Disapproval of Regulations by Congress: Procedure Under the Congressional Review Act, RL31160, Oct. 10, 2001. ↩︎
30. CRS, Congressional Oversight: An Overview, R41079, Feb. 22, 2010. ↩︎
31. U.S. Government Publishing Office, “Congressional Reports,” webpage, https://www.govinfo.gov/app/collection/CRPT/. ↩︎
32. U.S. House of Representatives, Strengthening Disease Surveillance, House Report 109-436, April 25, 2006. ↩︎
33. CRS, Treaties and Other International Agreements: The Role of the United States Senate, A study prepared for the Committee on Foreign Relations, United States Senate, January 2001. ↩︎
34. KFF, U.S. Participation in International Health Treaties, Commitments, Partnerships, and Other Agreements, report, Sept. 2010. ↩︎
35. CRS, International Food Aid: U.S. and Other Donor Contributions, RS21279, Nov. 12, 2013. ↩︎
36. CRS, Presidential Appointee Positions Requiring Senate Confirmation and Committees Handling Nominations, RL30959, Nov. 25, 2013. ↩︎
37. See also CRS, Senate Consideration of Presidential Nominations: Committee and Floor Procedure, RL31980; CRS, Appointment and Confirmation of Executive Branch Leadership: An Overview, R44083, June 22, 2015. ↩︎
38. Letter to President Barack Obama from 98 Members of Congress Regarding the FY2011 U.S. Contribution to the Global Fund, Oct. 27, 2009, accessed Feb. 2019, http://www.results.org/images/uploads/files/fy11_global_fund_letter_to_president_obama_10-27-09_with_co-signers_(final).pdf. ↩︎
39. CRS, PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, and Malaria Programs and Funding, RL34569, Jan. 29, 2009. See also KFF, PEPFAR Reauthorization: Side-by-Side of Legislation Over Time, brief. ↩︎
40. Sarah Ferris, “Timeline of Ebola outbreak,” The Hill, Oct. 2, 2014, http://thehill.com/policy/healthcare/219528-ebola-outbreak. The first cases of Ebola Virus Disease occurred in December 2013 in Guinea, a small country in Africa, but these, along with the growing number of cases spreading through the area, were not identified as Ebola until March 2014. Shortly thereafter, a neighboring country, Liberia, reported its first two cases, and there were early reports of possible Ebola cases in Sierra Leone. Reuters, “The Timeline of the Worst Ebola Outbreak Ever,” Oct. 18, 2014, http://www.newsweek.com/timeline-worst-ebola-outbreak-ever-276284. ↩︎
41. U.S. Senate, S.Res. 541; U.S. Congress, Continuing Appropriations Resolution, 2015 (P.L. 113-164). ↩︎
42. Obama White House Archives, “Emergency Funding Request to Enhance the U.S. Government’s Response to Ebola at Home and Abroad,” fact sheet, Nov. 5, 2014, https://obamawhitehouse.archives.gov/the-press-office/2014/11/05/fact-sheet-emergency-funding-request-enhance-us-government-s-response-eb. ↩︎
43. Statement of Senator Barbara Mikulski during Senate Appropriations Committee hearing, “U.S. Government Response: Fighting Ebola and Protecting America,” Nov. 12, 2014. ↩︎
44. U.S. Congress, Consolidated and Further Continuing Appropriations Act, 2015 (P.L. 113-235); KFF, The U.S. Global Health Budget: Analysis of Appropriations for Fiscal Year 2015, Dec. 22, 2014. For more information, see KFF, The U.S. Response to Ebola: Status of the FY 2015 Emergency Ebola Appropriation, Nov. 23, 2015. ↩︎
45. Most of this funding expired in FY 2019. ↩︎
46. HFAC, “Combatting the Ebola Threat,” subcommittee hearing, Aug. 7, 2014; Senate HELP and Appropriations Committees, “Ebola in West Africa: A Global Challenge and Public Health Threat,” joint committee hearing, Sept. 16, 2014; HFAC, “Global Efforts to Fight Ebola,” subcommittee hearing, Sept. 17, 2014; House E&C Committee, “Examining the U.S. Public Health Response to the Ebola Outbreak,” subcommittee hearing, Oct. 16, 2014. ↩︎
47. Approval of these reprogramming/transfer requests allowed DoD to transfer these funds from the Overseas Contingency Operations account and other accounts to the Overseas Humanitarian, Disaster, and Civic Assistance (OHDACA) account and to reprogram other funds in support of related efforts in Ebola-affected countries. In this case, several members in both chambers placed “holds” on their approval of requested funds, in effect instructing DoD to not take further action with the specified funds until their additional questions were answered and other requirements were fulfilled. House Armed Services Committee (HASC), “HASC Update: DOD Response to the Ebola Outbreak in West Africa,” fact sheet, Oct. 9, 2014; Kristina Wong, “House approves $750M in Ebola funding held up in Senate panel,” The Hill, Oct. 9, 2014; Office of Senator James Inhofe, “Inhofe Approves Reprogramming Request for Ebola Response Effort,” press release, Oct. 10, 2014; Kristina Wong, “Inhofe gives approval for $750M in Ebola funds,” The Hill, Oct. 10, 2014; CRS, “Increased Department of Defense Role in U.S. Ebola Response,” IN10152, Oct. 10, 2014; CRS, FY2015 Budget Requests to Counter Ebola and the Islamic State (IS), R43807, Dec. 9, 2014; White House, “U.S. Response to the Ebola Outbreak in West Africa,” fact sheet, Sept. 16, 2014. ↩︎
48. For example, Senator Patrick Leahy, “The Ebola Crisis,” floor speech, Congressional Record, 113th Congress, 2nd Session, Vol. 160, No. 130: Daily Edition S5550-1, Sept. 11, 2014; Rep. Mike Kelly, “Keeping America Safe From Ebola,” floor speech, Congressional Record, 113th Congress, 2nd Session, Vol. 160, No. 143: Daily Edition H8149-50, Nov. 20, 2014; Reps. Henry Waxman, Frank Pallone, and Diana DeGette, “Letter to Reps. Fred Upton, Joe Pitts, and Tim Murphy about Key Questions on  Ebola Outbreak,” correspondence, Oct. 1, 2014; Reps. Betty McCollum and Dave Reichert, “Global Health Caucus invites you to a briefing on the ‘Global Health response to Ebola’,” Dear Colleague letter, Nov. 13, 2014. ↩︎
49. HFAC Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations, “Combatting the Ebola Threat,” subcommittee hearing, Aug. 7, 2014; Senate HELP and Appropriations Committees, “Ebola in West Africa: A Global Challenge and Public Health Threat,” joint full committee hearing, Sept. 16, 2014; HFAC Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations, “Global Efforts to Fight Ebola,” subcommittee hearing, Sept. 17, 2014; House E&C Committee’s Subcommittee on Oversight and Investigations, “Examining the U.S. Public Health Response to the Ebola Outbreak,” subcommittee hearing, Oct. 16, 2014; Senate Appropriations Committee, “U.S. Government Response: Fighting Ebola and Protecting America,” full committee hearing, Nov. 12, 2014; HFAC, “Combating Ebola in West Africa: The International Response,”  full committee hearing, Nov. 13. 2014; HFAC Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations, “Fighting Ebola: A Ground-Level View,” subcommittee hearing, Nov. 18, 2014; SFRC Subcommittee on African Affairs, “The Ebola Epidemic: The Keys to Success for the International Response,” Dec. 10, 2014. ↩︎
50. KFF analysis of congressional member websites and press releases, Oct. 2021; U.S. House of Representatives Committee on House Administration, “Congressional Member and Staff Organizations,” webpage, https://cha.house.gov/member-services/congressional-member-and-staff-organizations/cmocso-registration-form. ↩︎

While current federal debate over policies to extend health insurance coverage to the remaining uninsured are largely focused on the 2.2 million people in the coverage gap and extension of increased premium help under the Affordable Care Act (ACA), which primarily benefit adults, many children (4.3 million¹ ) in the US were uninsured in 2020. Further, the number of uninsured children has been increasing in recent years: after steadily declining in the years prior, the uninsured rate for children increased significantly from 2016 to 2020, growing by 0.7 percentage points or over 450,000 children.²  Most of the changes during this period occurred from 2016 to 2018, with the overall children’s uninsured rate remaining stable from 2018 to 2020. The vast majority of uninsured children are already eligible for Medicaid or CHIP, so policy action to extend children’s coverage largely focuses on enrollment and retention. Outreach to inform children and families about Medicaid/CHIP coverage may facilitate child enrollment, and continuous eligibility requirements for Medicaid/CHIP could prevent loss of coverage. Research also shows that expanding coverage for adults in households with children also can increase children’s coverage, so recent federal efforts to extend coverage for adults in the coverage gap could have spillover effects for children’s coverage.

This brief examines characteristics of uninsured children in 2020 and discusses how current policy proposals, including outreach efforts, continuous eligibility requirements, and closing the coverage gap, could affect children’s health coverage. Recent efforts to expand coverage for adults could benefit children’s coverage, especially for children in non-expansion states if the coverage gap is filled as proposed by the Build Back Better Act (BBBA).

What do we know about uninsured children?

Most uninsured children in the US are school-aged, live in one or two parent families, and are US citizens (Figure 1). School-aged children (ages 6-18) make up almost three-quarters of uninsured children in the US; however, the children’s uninsured rate, or percentage of children with no health coverage, among infants was higher than the uninsured rate for children ages 1-5 and school aged children (Figure 1 and Appendix Figure 1). A majority of uninsured children live in one or two parent families (60.6%), and children in two parent families are less likely to be uninsured than those in multi-generational families, married adults, adults living together, single individual families, and other family types. Though US citizens make up the vast majority (89.7%) of uninsured children, they are less at risk of being uninsured than children who are not US citizens. While the children’s uninsured rate overall and for most demographic groups held steady in recent years, children who are not citizens and have been US residents for less than 5 years did experience significant increases in their uninsured rates from 2018 to 2020 (Appendix Table 1).

Children of color are disproportionately uninsured. Hispanic children make up the largest share (43.0%) of uninsured children (Figure 1). Children of color, together, make up nearly two-thirds of all uninsured children, but only make up 50.5% of all children in the US. Further, Black, Hispanic, and American Indian/Alaska Native children are more likely to be uninsured compared to white children (Appendix Figure 1). Black children experienced significant increases in their uninsured rates from 2018 to 2020 despite stability in the overall children’s uninsured rate (Appendix Table 1).

Children in poverty are more likely to be uninsured and make up a disproportionate share of uninsured children. Children living below 100% of the Federal Poverty Level (FPL; the federal poverty level was $20,852 for a family of two adults and a child in 2020) make up over a quarter of uninsured children, but account for only 16.5% of children in the US (Figure 1). The majority (53.5%) of uninsured children live below 200% FPL, and the vast majority (86.2%) live below 400% FPL. Children living below poverty are more likely to be uninsured compared to children living between 200 – 400% FPL and over 400% FPL (Appendix Figure 1). Further, children with no workers in their family are at more risk of being uninsured than those children with multiple workers or one full-time worker in their family. However, the vast majority (77.9%) of uninsured children have at least one full-time worker in their family, highlighting that many children live in families with lower income workers who likely do not obtain health coverage through their employer.

The uninsured rates for children in 2020 varied across states, ranging from 2.3% of children in New York to 12.0% in Alaska (though estimates for some states were not reportable) (Figure 2). Texas and Florida have the largest number of uninsured children, together accounting for almost one third (20.6% in Texas and 10.7% in Florida) of all uninsured children in the US (Figure 2).

How could current policy proposals reach uninsured children?

Outreach may improve children’s coverage rates since the vast majority of uninsured children are eligible for Medicaid or subsidized Marketplace coverage. In general, nearly all low-income children in the US are eligible for Medicaid/CHIP, with 49 states covering children at or above 200% FPL and more than a third of states covering children at or above 300% FPL. Two-thirds of all uninsured children are eligible for Medicaid/CHIP, and another 10.9% are eligible for subsidized Marketplace coverage (including those eligible under subsidies available under the American Rescue Plan Act) (Figure 3). Most remaining uninsured children are not eligible for financial assistance for coverage because their family has access to employer-based coverage. Children eligible for coverage may still be uninsured for several reasons including administrative barriers, language barriers and lack of internet access, lack of program knowledge and inadequate outreach, among others. Outreach can connect children to Medicaid/CHIP coverage, with outreach efforts following the implementation of the ACA contributing to children’s coverage gains leading up to 2016 even though the ACA did not materially increase children's eligibility for coverage. The current BBBA budget reconciliation package proposes funding for outreach and enrollment efforts through 2025 to inform individuals of their coverage options. The Biden Administration also recently extended the open enrollment period by 30 days, provided additional funding for Federally-facilitated Marketplace (FFM) Navigators, and re-launched the “Champions for Coverage” initiative in efforts to expand access to health coverage.

Closing the coverage gap could also affect the number of uninsured children. Children living in one of the 12 states that have not expanded Medicaid to adults under the ACA (non-expansion states) were over two times as likely to be uninsured as children in expansion states in 2020 (Appendix Figure 1). The uninsured rate increased significantly by 1.3 percentage points from 2016 to 2020 for children living in non-expansion states, while the uninsured rate held steady for children in expansion states (Appendix Table 1). Uninsured children are disproportionately concentrated in non-expansion states: only 35.2% of US children live a non-expansion state, but a majority of uninsured children (53.8%) live in non-expansion states (Figure 1).

Studies show a link between expanding parent Medicaid eligibility and growth in children’s health coverage.^{3 ,4 ,5 ,6}  While research shows that children are more likely to gain and maintain coverage when parents gain access to the same coverage program, parents also say that affordability is the most important factor they care about in their children’s coverage, and they would be willing to enroll them in separate coverage for a lower cost. Following the implementation of the ACA, expansion states saw growth in children’s health coverage rates even though eligibility for children did not expand. One study estimates 710,000 low-income children gained coverage post ACA implementation and an additional 200,000 children would have gained coverage if all states had expanded Medicaid. Uninsured children are disproportionately concentrated in non-expansion states; thus, expanding access to health coverage to adults in the coverage gap could increase coverage for children.

The current version of the BBBA seeks to temporarily close the coverage gap by allowing people living in states that have not expanded Medicaid to purchase subsidized coverage on the ACA Marketplace through 2025. The proposal also extends provisions in the American Rescue Plan Act (ARPA) passed earlier this year that provide additional financial assistance for low-income people purchasing Marketplace plans through 2025. Parents in the coverage gap seeking Marketplace coverage through the “no wrong door” application process could enroll their eligible children in Medicaid/CHIP coverage. Additionally, there are provisions in the BBBA to increase in the federal Medicaid match rate for the expansion population (from 90% to 93%) through 2025 on top of already passed fiscal incentives in the ARPA. This could discourage states that have already expanded Medicaid from dropping, and could encourage new states to implement Medicaid expansion, particularly after the temporary effort to close the coverage gap expires.

Continuous eligibility for children in Medicaid/CHIP reduces gaps in health coverage. States currently have the option to provide 12 months of continuous coverage, and as of January 2020, 31 states provide 12-month continuous eligibility to children in Medicaid/CHIP. The BBBA includes a requirement for all states to provide 12-months of continuous coverage for children with Medicaid/CHIP, which would allow children to remain enrolled for a full year unless the child withdraws, moves, or turns 19. This provision could reduce children’s health coverage disruptions, which children of color are more likely to experience, and may reduce the number of uninsured children.

Looking Ahead

As congress continues to debate the BBBA, it is uncertain when an agreement will be reached and what provisions impacting children’s health coverage will remain in the final bill. If passed with current provisions, the bill has the potential to improve children’s health coverage.

As COVID-19 vaccines are rolled out for young children, linking children to coverage may be a step in helping children access vaccines. While the vaccine is available at no cost irrespective of insurance status, research shows uninsured children have lower vaccination coverage generally, potentially stemming from difficulties with access to care, information, or transportation. More broadly, children who lack insurance coverage have worse access to health care and face long-term consequences for their health and development. Given the range of challenges children have faced during the pandemic, actions to extend health insurance coverage to those lacking it may address some of the negative consequences.

 

1. KFF analysis of the 2021 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). ↩︎
2. KFF analysis of the 2021 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). ↩︎
3. Julie Hudson and Asako Moriya, “Medicaid Expansion For Adults Had Measurable ‘Welcome Mat’ Effects On Their Children”, Health Affairs 36,9 (September 2017): 1643-1651. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0347. ↩︎
4. Adam Sacarny, Katherine Baicker, and Amy Finkelstein, “Out of the Woodwork: Enrollment Spillovers in the Oregon Health Insurance Experiment”, National Bureau of Economic Research, No. w26871 (March 2020), https://www.nber.org/system/files/working_papers/w26871/w26871.pdf. ↩︎
5. Lisa Dubay and Genevieve Kenney, “Expanding Public Health Insurance to Parents: Effects on Children's Coverage under Medicaid”, Health Services Research: 38,5 (2003): 1283–1301. https://doi.org/10.1111/1475-6773.00177. ↩︎
6. Jennifer Devoe, Miguel Marino, Heather Angier, et al., “Effect of Expanding Medicaid for Parents on Children’s Health Insurance Coverage: Lessons From the Oregon Experiment”, JAMA Pediatrics, 169,1 (2015). https://doi:10.1001/jamapediatrics.2014.3145. ↩︎