With millions of U.S. school children returning to in-person learning for the 2021-2022 school year, schools are grappling with how best to keep students, and the larger school community, safe as the COVID-19 pandemic continues and most elementary students are still not eligible for vaccination. While school policy is primarily made at the state and local levels, the Centers for Disease Control and Prevention (CDC) has issued guidance recommending a layered approach for COVID-19 prevention and mitigation in K-12 schools that promotes, among other things, vaccination as the best way to prevent severe illness, hospitalization and death, universal masking for students, teachers, staff, and visitors to schools, and regular screening testing of students and staff, particularly those who are unvaccinated, so that measures can be taken to prevent further transmission.

To better understand the extent to which states have adopted policies consistent with CDC guidance, we examined state policies for all 50 states and DC focused on COVID-19 prevention strategies in K-12 public schools for the 2021-2022 school year. We looked at policies in the following areas: vaccine mandates for school employees and students; mask requirements; and requirements for COVID-19 screening testing of students and staff. We also sought to identify where states left such decisions up to local school districts. We used data from the National Center for Education Statistics on projected public school enrollment in 2021 to obtain the number of elementary and secondary public school students by state.

As of October 5, 2021, we find that most states have left COVID-19 prevention decisions up to local school districts, and in some cases, have prohibited local districts from implementing them. As a result, there is wide variation in the use of such strategies across the country and within states, including by school district or even by individual schools. In addition, large shares of K-12 public school students live in states that do not mandate COVID-19 prevention strategies in schools, though, in many cases allow local districts to implement such measures and do provide funding and other assistance. Specific findings in each area are as follows:

• COVID-19 Vaccine Mandates: Most states (40) do not require school employees to get vaccinated. Of the 11 that do, they are primarily in the Northeast and West. Overall, seven in ten (70%) K-12 public school students live in states without such requirements while the remainder (30%) are in the 11 states that have vaccine requirements.So far, California is the only state to mandate that all eligible students be vaccinated, though that requirement is not scheduled to take effect until July 1, 2022 for students in grades 7-12. The mandate for younger children will take effect six months following full FDA approval of the vaccine for the age group. This is likely to be an area that will change, as all states mandate vaccines for school children in many instances including for measles, mumps, and rubella (MMR), diphtheria, tetanus, and pertussis (DTaP/Tdap), and chickenpox.

• Mask Requirements: Currently, 18 states require masks in school—11 states have broader statewide face mask requirements that also apply to schools, while mask mandates in 7 of these states are specific to schools (and certain other settings). Twenty-five states do not have a statewide requirement for masks in schools but allow for local school districts to institute such requirements. An additional 8 states prohibit schools from requiring masks, though these bans are being challenged in court in nearly all of the states.States in the Northeast are most likely to require masks, and none prohibit them, while states in the Midwest are the least likely to require them. Two thirds of states that prohibit masks are in the South. The majority of K-12 public school students either live in states that do not require masks (43%) or prohibit such requirements (25%). About one-third (32%) live in states that do require them (although because of decisions by local school districts in many states to require masks, a larger share of students attend schools that require them). None of the 8 states that prohibit masks have vaccine mandates in schools.

• COVID-19 Screening Testing: Almost all states (45) have left COVID-19 testing decisions up to local school districts. Both DC and New York are exceptions, with each requiring screening for all schools. DC conducts opt-out surveillance testing of a random sample of at least 10% of asymptomatic students each week, while New York requires weekly testing of all teachers and staff, with an opt out for those who are fully vaccinated. Four states require testing in certain situations: Nevada requires students who are not fully vaccinated to be regularly tested if they travel to other schools for athletic events; Michigan requires all unvaccinated individuals ages 13-19 participating in school and non-school sponsored sports to be tested weekly; Utah has a Test to Stay policy to support in-person education that requires testing of all students during COVID-19 outbreaks; and Washington requires student athletes who are not fully vaccinated but involved in high-contact sports to be regularly tested.Several states, including Maine and Massachusetts, have established voluntary pooled testing programs in which local districts can participate, and other states are using federal COVID-19 funding to support schools that would like to implement COVID-19 testing programs.

Implications

States have staked out different approaches to mandating COVID-19 prevention measures in K-12 public schools, although most have left decisions up to local school districts, where most school policies are made, or even to individual schools. While some states have adopted CDC-recommended COVID-19 strategies, most are not requiring schools to implement proven and effective COVID-19 interventions that can help to keep children and school communities safe. As a result, there is wide variation in the use of such strategies across the country and within states, including by school district or even individual schools. In addition, large shares of K-12 public school students live in states that do not mandate such strategies, including 70% of students who live in states that do not require school staff to get vaccinated and more than two-thirds who live in states that either do not require masks or prohibit them.  Most states also leave decisions regarding the use of regular COVID-19 testing, a proven public health intervention to identify those who might be infectious and reduce onward transmission, up to local districts or individual schools, although in several cases, states make resources available to support them including in instituting school-wide, regular screening programs.

This analysis is based on data as of October 5, 2021. For the latest data on COVID-19 prevention strategies in schools, please see https://www.kff.org/report-section/state-covid-19-data-and-policy-actions-policy-actions/#schools.

As the COVID-19 pandemic’s focus shifts from urban to rural areas, and more people resume public activities, a new KFF analysis of case and death data from the Centers for Disease Control and Prevention reveals narrower disparities affecting Black and Hispanic people compared to White people now than earlier in the pandemic.

The analysis examines trends in cases and deaths since early in the pandemic where race and ethnicity is known. While cumulative data show that Black, Hispanic and American Indian and Alaska Native people have been disproportional impacted overall, recent data show much closer rates of new cases and deaths among White, Black and Hispanic people. In contrast, American Indian and Alaska Native people are experiencing higher rates of new cases than other groups.

Some factors likely contributing to these shifts:

• COVID-19 vaccinations have increased protections and reduced illness and death across all racial and ethnic groups. Vaccination rates among Black and Hispanic adults also are approaching parity with the rate among White adults. That’s a significant shift from earlier this year, when vaccination rates lagged among Black and Hispanic adults in part due to access barriers. The latest KFF COVID-19 Vaccine Monitor report now shows the uninsured, Republicans, rural residents and White Evangelical Christians as the least vaccinated groups.
• The pandemic initially hit hardest in urban areas, which often include a racially diverse population, but is increasingly hitting more rural areas, which have higher concentrations of White and American Indian and Alaskan Native people.
• Earlier in the pandemic, when most states implemented social distancing measures and limited public activities, risk of exposure and infection was highest for essential workers, who continued to work outside their home and are disproportionately people of color.

The analysis notes that while disparities have narrowed, many of the underlying structural inequities in health and health care and social and economic factors that placed people of color at increased risk early in the pandemic remain. They may remain at risk as the pandemic continues to evolve or if future health threats emerge.

As the Congressional debate over budget reconciliation legislation intensifies, stakeholders are keeping a close eye on a proposal to allow the federal government to negotiate drug prices in Medicare, which is currently prohibited under federal law. The so-called “non-interference clause” prohibits the federal government from “interfering” in negotiations between drug companies and the private plans that deliver Part D coverage, and also prohibits the government from requiring a particular formulary or price structure for drugs. The proposal under consideration amends the non-interference clause by adding an exception that would allow the government to negotiate prices with drug companies for a relatively small number of high-cost drugs, with an excise tax levied on drug companies that do not agree to participate in the negotiation process or comply with the negotiated price. This proposal would yield savings upwards of $450 billion, based on an earlier estimate from the Congressional Budget Office.

The pharmaceutical industry’s latest ad campaign claims that drug price negotiation would “restrict access to medicines in Medicare” by removing “a provision that protects access to medicines” and that patients “would be stuck with whatever medicines the government says you can have.” Another drug industry ad says that allowing the government to negotiate drug prices means “politicians…[will] decide which medicines you can and can’t get.”

This is not accurate. In fact, the proposed drug price negotiation program does not authorize the federal government to decide which medications people on Medicare can and cannot get and does not establish or require a particular prescription drug formulary. Insurers that offer Medicare prescription drug plans would continue to make decisions about which drugs to cover, or not, subject to protections provided under current law and regulations. The legislation under consideration leaves in place the non-interference clause and its specific restrictions with the exception of the proposed drug price negotiation program. Under this program, the negotiation process would not apply to most prescription drugs, instead focusing on a relatively small number with the highest spending and lacking generic or biosimilar competitors.

While there is nothing in the proposed legislation that would allow the federal government to dictate which drugs Medicare beneficiaries can access, it is possible that downward pressure on prices from negotiation could lead drug companies to bring fewer drugs to market. The Congressional Budget Office has estimated that reductions in future profits of 15% to 25% for high revenue drugs, which CBO expects would be similar to the effect of the current drug price negotiation proposal, would lead to 2 fewer drugs in the first decade (a reduction of 0.5%), 23 fewer drugs over the next decade (a reduction of 5%), and 34 fewer drugs in the third decade (a reduction of 8%). But the effect of lower prices on the number and type of new drugs that do and don’t come to market in the future is impossible to know with certainty. CBO does not forecast whether the drugs that don’t come to market would be innovative lifesaving treatments or “me too” drugs that offer little value in terms of improved health. CBO also notes that lower prices could potentially improve affordability and access to drugs for patients, leading to improved health.

Allowing the federal government to negotiate drug prices, which is supported by a large majority of the public, would lower cost sharing and premiums for Medicare beneficiaries and produce significant savings for the federal government that could be used to cover the costs of other spending priorities, such as adding new Medicare dental, hearing, and vison benefits, filling the Medicaid “coverage gap”, and making permanent subsidy enhancements for people in Marketplace plans. With much at stake in the outcome of the debate over this proposal, it’s no surprise that the rhetoric is getting heated. But while the pharmaceutical industry may want to frame the debate over drug price negotiation by focusing on the federal government limiting access to medications, this framing doesn’t accurately reflect what’s in the current legislative proposal. There are trade-offs involved in the proposal to negotiate drug prices, but that is not one of them.

Since the rollout of the COVID-19 vaccines began, one issue that has been of focus is racial equity in COVID-19 vaccination rates. Ensuring equity in COVID-19 vaccinations is important given that COVID-19 has disproportionately affected people of color and may widen underlying disparities in health. Data are key for identifying disparities in COVID-19 vaccination rates and directing resources and efforts to address them. However, there are gaps in the federally reported COVID-19 vaccination data by race/ethnicity from the Centers for Disease Control and Prevention (CDC). To help fill these gaps in federal data, KFF and others have conducted ongoing analysis of state-reported vaccination data by race and ethnicity and regular COVID-19 Vaccine Monitor surveys with adults. These data have provided further insight into COVID-19 vaccination patterns by race/ethnicity, but also are subject to limitations. This brief provides an overview of these data sources, discusses their limitations, and explains why their findings may vary.

Vaccination Rates Across Data Sources

The federal and state administrative data and Vaccine Monitor surveys all show that Black and Hispanic people have been less likely to receive a COVID-19 vaccine compared to their White counterparts since the vaccination rollout began but that these disparities have narrowed over time. However, they vary in findings of the magnitude of this narrowing (Figure 1 and Table 1):

• The federal data from the CDC show that between late April and late September 2021, the percentage point gap between White and Black rates for the whole population fell by 2 percentage points (from 8 to 6 percentage points) while the gap between White and Hispanic rates fell by 9 percentage points (from 8 to -1 percentage points).
• The state-reported data find that the gap between White and Black rates for the total population fell by 6 percentage points over this period (from 14 to 8 percentage points), while the difference between White and Hispanic rates fell by 9 percentage points (from 13 to 4 percentage points).
• Vaccine Monitor survey data show the same trend with the difference between rates for White and Black adults falling by 8 percentage points (from 9 to 1 percentage points) and the gap between White and Hispanic adults narrowing by 15 percentage points (from 13 to -2 percentage points).

As of September 2021, the federal data from CDC show similar vaccination rates between Hispanic and White people, with lower rates persisting for Black people, and the highest rate for American Indian and Alaska Native and Asian people. Analysis of state data finds that Black and Hispanic people are less likely than White people to be vaccinated, but with a narrower gap for Hispanic people. The Vaccine Monitor survey data show that the gaps in rates for Black and Hispanic adults compared to White adults have closed, with no statistically significant differences in vaccination rates across these groups. A Pew Research Center survey conducted in August had similar findings.

This variation in findings reflects differences in what the data sources are measuring. Vaccination rates from the Vaccine Monitor surveys are based on adults, while the rates based on federal and state administrative data are for the total population (including children under 12 who are currently not eligible for vaccination). The inclusion of children in vaccination rates may lead to larger disparities due to racial differences in vaccination rates among adolescents eligible for the vaccines (ages 12-17) and because of the greater racial diversity of children relative to adults. Moreover, both the survey and administrative data are subject to different sources of measurement error, as discussed further below.

Federal COVID-19 Vaccination Data by Race/Ethnicity

The CDC reports the distribution of COVID-19 vaccinations and the percent of the total population who have received a COVID-19 vaccine by race/ethnicity at the national level. However, as of September 27, 2021, information on race/ethnicity was missing for over 40% of people who received at least one dose. Moreover, the data do not represent all states and jurisdictions, since not all states and territories are reporting demographic data on vaccine recipients to CDC. Given these data gaps, CDC indicates that the data are not generalizable to the entire population of individuals with COVID-19 vaccination. CDC does not report state-level data on COVID-19 vaccinations by race/ethnicity. Moreover, although CDC reports vaccinations by race/ethnicity and age separately, it does not publicly report data that allows for analysis of vaccinations by race/ethnicity and age. As such, the data cannot be used to examine whether there are larger racial disparities in vaccination rates among certain age groups, such as adolescents or younger adults.

State COVID-19 Vaccination Data by Race/Ethnicity

In the absence of CDC reporting state-level COVID-19 vaccination data by race/ethnicity, KFF has conducted ongoing analysis of data reported directly by states. As of September 20, 2021, 45 states, including Washington, D.C., were publicly reporting data on people who had received at least one COVID-19 vaccine by race/ethnicity and KFF was able to calculate total vaccination rates by race/ethnicity across 43 of these states. (Two states were excluded from the total due to differences in how they report their data). In general, these data are more complete than the data reported by CDC, with lower shares of vaccinations with unknown or missing race/ethnicity in most states. However, they also have gaps, limitations, and inconsistencies. As with the federal data, they do not include data from all states and jurisdictions and some states have relatively high shares of vaccinations with unknown race/ethnicity. For example, in Alabama, 37% of vaccinations had unknown race as of September 20, 2021. Further, states vary in their racial/ethnic classifications used to report the data, including how they classify people who identify as more than one race. Some state reported data does not include vaccinations administered through federal programs, including the Indian Health Service or the Long-Term Care Partnership Program.

COVID-19 Vaccine Monitor and Other Survey Data

Since December 2020, KFF has been conducting ongoing, nationally representative surveys of U.S. adults through the COVID-19 Vaccine Monitor. While these surveys have a broader purpose of measuring vaccine confidence, information needs, trusted messengers and messages, we have also used them to track the share of adults who report being vaccinated for COVID-19 over time. These surveys rely on probability-based sampling methods and researchers take extra steps to ensure the inclusion of populations that are often missed in surveys (including interviewing in English and Spanish and oversampling pre-paid cell phones that are commonly used by lower-income adults). Each survey also includes extra interviews with Black and Hispanic adults – using weighting to adjust survey respondents to match the distribution of adults in the U.S. — to be able to have greater statistical confidence when reporting on those groups (see the full methodology for more details).

Like all surveys, the Vaccine Monitor surveys are subject to a margin of sampling error around each estimate. For the September survey, the margin of sampling error was plus or minus 3 percentage points for the full sample, 4 percentage points for White adults, and plus or minus 7 percentage points for both Black and Hispanic adults. In addition, surveys may have other sources of error, including nonresponse error (certain types of people choosing not to participate in the survey or declining to answer the question about whether they have been vaccinated), measurement error (respondents not understanding the question that was asked), and social desirability bias (respondents giving answers they think the interviewer wants to hear). Despite these potential sources of error, the Vaccine Monitor surveys have tracked quite closely with CDC estimates of the share of adults overall vaccinated over time, and a recent Pew Research Center analysis of 98 different public polls conducted by 19 different polling organizations between December 2020 and June 2021 (including the Vaccine Monitor surveys) found that polling estimates of the adult vaccination rate have been within about 2.8 percentage points, on average, of the rate calculated by the CDC.

Conclusion

Data are pivotal for identifying and addressing disparities in health and health care. Over the course of the COVID-19 pandemic, gaps in data available by race/ethnicity have limited efforts to understand and address disparities. The availability and quality of data have improved over the course of the pandemic, but data gaps and limitations remain. To help fill gaps in federally reported data on COVID-19 vaccinations by race/ethnicity, KFF and others have conducted ongoing analysis of state-reported data on COVID-19 vaccinations and regular COVID-19 Vaccine Monitor surveys of adults, which have provided increased understanding of COVID-19 vaccination patterns by race/ethnicity. This, in turn, has helped to direct resources and efforts to address racial disparities in vaccination rates. While the federal, state, and survey data all show narrowing racial disparities in COVID-19 vaccination rates over time, they vary in the magnitude of this narrowing, with some surveys showing that gaps have closed, while the administrative data pointing to some remaining differences. This variation in findings reflects both differences and limitations across the datasets. Going forward, continued efforts to increase the availability of comprehensive, high-quality data will be key for identifying and addressing disparities for COVID-19 and in health and health care more broadly. Moreover, it will be important to continue to prioritize equity as vaccination efforts continue, people become eligible for booster shots, and eligibility expands to children, particularly given significant racial diversity of children.

Medicaid is a key source of coverage for low-income pregnant people in the United States, covering more than four in ten births nationally, but many people who qualify for Medicaid because they are pregnant lose that coverage 60 days postpartum, especially if they live in a state that has not expanded Medicaid. In recent years there has been a growing interest among state and federal policymakers in extending Medicaid postpartum coverage beyond the 60-day mark to help address racial disparities and improve maternal and infant health. Earlier this year, federal legislation was enacted that gives states a temporary option to extend postpartum coverage beyond 60 days, and Congress is currently considering additional legislation to require such extended coverage.

Federal law requires that all states cover pregnant individuals with incomes at least up to 138% of the federal poverty level (FPL), although many states have set higher income eligibility levels, and they must extend coverage for 60-days postpartum. Some people lose that coverage after the postpartum period because they have no eligibility pathway even though they have incomes below the federal poverty level. Following the 60-day postpartum period, in states that have adopted the Affordable Care Act (ACA)’s Medicaid expansion, individuals with incomes below 138% FPL have a continued pathway to Medicaid coverage and those with higher incomes may qualify for subsidized coverage through the ACA marketplace plans; however, individuals in non-expansion states may become uninsured because Medicaid eligibility levels for parents are much lower than for pregnant people. For example, in Alabama, which has not sought a postpartum coverage extension, the Medicaid eligibility level for parents is 18% FPL, which is approximately $4,000/year for a family of three.

The federal American Rescue Plan Act (ARPA) enacted in March 2021 gives states the option to extend postpartum coverage to pregnant individuals to a full year. The coverage option is available for five years starting on April 1, 2022 and states must provide a full scope of benefits without limitations on coverage during the extension. Prior to ARPA’s enactment, states had to seek permission from the Centers for Medicare and Medicaid Services (CMS) by applying for a Section 1115 waiver to extend the postpartum period beyond 60 days, although none of these applications were approved until April 2021. Even though the new option under ARPA will not be effective until April 2022, postpartum coverage has been continuous since the start of the coronavirus pandemic because Medicaid disenrollment has been suspended during the public health emergency.

Largely in response to the new federal option, at least 25 states have taken steps to extend Medicaid postpartum coverage. To date, most of these are expansion states, but actions in non-expansion states will ensure continued coverage following the current postpartum period. Prior to the enactment of ARPA, California and Texas had limited state-funded postpartum coverage in place and a few states had submitted waivers to CMS to extend postpartum coverage through Medicaid, although, in some cases, targeted to narrow groups, such as those with a diagnosed substance use disorder, or for less than 12 months. States often seek approval of a demonstration waiver to do something they cannot do under current law. A few states are still seeking waivers to implement prior to April 2022 or to extend postpartum coverage in ways more limited than the new ARPA option.

Recent state actions to extend postpartum coverage for 12 months include:

• Thirteen states (California, Colorado, Connecticut, DC, Maine, Maryland, Minnesota, New Jersey, Ohio, South Carolina, Tennessee, Washington, and West Virginia) enacted legislation, a first step to implementing a coverage extension;
• New York and North Carolina are debating proposed legislation;
• Two states (Indiana and Pennsylvania) announced plans to adopt the new option using existing authority; and
• Illinois received approval to extend postpartum coverage for 12 months through a waiver (waivers are pending in three states—Florida, Massachusetts, and Virginia).

Although recent federal action has prompted many states to consider extending postpartum coverage, some states still won’t have a pathway for coverage beyond the current 60-day postpartum period, and Congress is currently considering proposals to require such coverage. Uneven adoption of the ARPA option means postpartum individuals in many states remain at risk of losing Medicaid coverage just two months after giving birth. Postpartum people with household incomes below the poverty level in non-expansion states often do not have another coverage option and become uninsured when they lose Medicaid coverage. Currently, Congress is considering a provision in the Build Back Better Act that would require all states to extend Medicaid postpartum coverage from 60 days to 12 months, ensuring continuity of Medicaid coverage for postpartum individuals in all states to more broadly reduce disparities and improve maternal and infant health outcomes. However, there is a push to lower the overall amount of spending in the package, and the extension of postpartum coverage could be forced to compete against other priorities.

To track updated state-by-state activity on Medicaid postpartum coverage, please visit our Medicaid Postpartum Coverage Extension Tracker.

A new KFF analysis examines key characteristics of children with special health care needs, the affordability and adequacy of their health coverage, and the implications for such children of potential new federal Medicaid money to assist families in caring for them.

Medicaid is a significant source of coverage for medical, behavioral health, and long-term services and supports for children with special health care needs, including home and community-based services (HCBS) that they need to live at home with their families. During the pandemic, children have experienced health care disruptions, mental health challenges, and economic hardships, and these issues may have been intensified for those with special health care needs.

The American Rescue Plan Act provides a temporary increase in federal Medicaid matching funds for state spending on HCBS. As part of the budget reconciliation legislation, the House currently is considering $190 billion in additional Medicaid HCBS funding that states could use to support the HCBS provider workforce, offer new or expanded HCBS benefits, and/or serve more HCBS enrollees, though the final funding amount has not yet been set.

The analysis provides context for those ongoing policy discussions. Key findings include:

• Medicaid/CHIP covers almost half of the 13.9 million children in the U.S. with special health care needs, though the share varies by state.

• Children with special health care needs covered by both Medicaid/CHIP and private insurance have the greatest health care needs, and children who are covered only by Medicaid/CHIP are more likely to have greater health needs compared to those with private insurance only.

• While families of Medicaid/CHIP-only children with special health care needs are more likely to face financial difficulty, they find their health care more affordable than those with private insurance only. This is due to Medicaid’s cost-sharing protections.

• Even though children with special health care needs covered by Medicaid/CHIP-only have greater health care needs, they are more likely than those with private insurance alone to report that their benefits are always adequate to meet their needs.

For the full analysis, as well as other data and analyses about health care priorities in the budget reconciliation discussion on Capitol Hill, visit kff.org.

The months-long decline in COVID-19 deaths among nursing home residents and staff reversed course this summer as the Delta variant dominated, with mortality increasing five-fold from 350 deaths in July to nearly 1,800 in August, finds a new KFF analysis.

The analysis also finds increases in nursing home COVID-19 cases and deaths were steeper than those in the broader community between July and August.

Nursing home deaths in August were the highest reported since February, when 5,300 nursing home residents and staff died of COVID-19, but still far below the peak of over 22,000 deaths in December 2020. COVID-19 cases in nursing homes also rose more than four-fold between July and August.

The findings illustrate that, while recent news coverage has focused heavily on the impact of the pandemic on children and unvaccinated adults, COVID-19 continues to disproportionately affect older adults and people with disabilities — populations that were hit particularly hard in the first year of the crisis.

The recent endorsement by the Centers for Disease Control and Prevention of booster shots for older adults and others at high risk of serious illness, including those in nursing homes, could help curb new cases and deaths. In addition, the Biden administration has recently announced staff vaccination mandate for nursing homes.

A second KFF analysis released this week similarly finds that COVID-19 deaths among older adults in the U.S. more broadly also have been on the rise amid the Delta variant outbreak, though not reaching the levels seen earlier in the pandemic.

Among 38 states in the new analysis, four of the five with the lowest COVID vaccination rates for older adults – Arkansas, Alabama, Georgia, and Nevada – had higher death rates than the national average, with a combined death rate nearly two times the national average for this age group during the recent surge. Had the death rate in the 10 least vaccinated states been the same as the death rate in the 10 most vaccinated states, there would have been 7,623 fewer deaths among older adults during the Delta surge in these states.

For more data and analyses about COVID-19, visit kff.org.

Staff and residents at long-term care facilities were particularly hard-hit by the first year of the pandemic, accounting for 31% of all COVID-19 deaths in the US as of June 30, 2021.  KFF analysis found that, following vaccine rollout in winter 2020-2021, weekly cases and deaths in long-term care facilities (including nursing homes, assisted living facilities, ICF/IIDs, and other settings) dropped, reaching an all-time low in June 2021, just prior to the rapid increase in national cases and deaths due to the Delta variant. As Delta spread across the US in the summer of 2021, much of the focus was on young children at risk during back-to-school; however, with the Delta surge, older Americans, especially those 85 and older, continued to face higher risk of death due to COVID-19 compared to younger Americans, according to the CDC. This data note analyzes federal nursing home data to determine the ongoing impact of the pandemic on COVID-19 cases and deaths among staff and residents. See methods box for more details.

Nursing homes across the US reported nearly 1,800 COVID-19 deaths among residents and staff in August 2021, the highest number of COVID-19 deaths reported in a single month since February 2021 and a steady increase from the approximately 350 deaths reported in July 2021 (Figure 1). This jump in the total number of deaths due to COVID-19 reverses the sustained pattern of decreasing deaths since CMS implemented the Pharmacy Partnership For Long-Term Care, even though the number of nursing home deaths due to COVID-19 in August 2021 was still far below the peak of over 22,000 seen in December 2020 (Table 1).

Deaths attributable to COVID-19 increased at a faster rate in nursing homes than among all others in the community between July and August 2021. The number of COVID-19 deaths among staff and residents in nursing homes quadrupled between July and August, while COVID-19 deaths in the community doubled in the same time period (Table 1). During this period, deaths increased at a faster rate among nursing home residents than among nursing home staff (423% versus 274%). While the vast majority of COVID-19 deaths happened outside of nursing homes in July and August, the high rate of increase within nursing homes indicates that residents and staff in these settings are at risk of death during the Delta surge, and not immune from the most recent wave.

COVID-19 cases also increased more rapidly in nursing homes than in the community. Nursing home cases grew by 440% (from 9,000 to 48,800) between July and August 2021, with a slightly higher increase in resident cases (483%, growing from 3,200 to 19,000) than staff cases (416%, growing from 5,700 to 29,600). Cases outside of nursing homes increased by 224% in the same time period, growing from 1.3 million to 4.2 million (Table 1).  Similar to COVID-19 deaths, the vast majority of COVID-19 cases occurred outside of nursing homes. However, the high rate of increase of nursing home cases shows the connection between community spread and the spread of the virus in nursing homes.

While recent news coverage has focused heavily on the impact of the pandemic on children and unvaccinated adults, the pandemic continues to disproportionately impact older adults and people with disabilities. The CDC recently endorsed an extra dose of the COVID-19 vaccine for a number of additional populations, including residents of long-term care settings, which would make booster shots available to people who live in nursing homes. In addition, the Biden administration has recently announced staff vaccination mandate for nursing homes. As of mid-September 2021, about 84% of all nursing home residents and 64% of all nursing home staff are vaccinated. Vaccines coupled with boosters may reverse the recent trend of rising cases and deaths within nursing homes, though ongoing spread in the community continues to have an impact on residents and staff.

The House of Representatives is considering a provision of the Build Back Better Act that would create a universal paid family and medical leave program. This post takes a look at this proposal, key policy questions, and what it could mean for women and families.

What is in the proposal?

Effective July 2023, the proposal would guarantee 12 weeks of paid family and medical leave annually to all workers in the U.S., including those working for private employers, state, local, and federal governments, as well as self-employed and gig workers. Workers would be covered through either the new federal program or a qualified existing employer or state paid leave program. The proposal would replace 85% of wages for earnings up to $290 per week ($15,080 annually), plus 75% of average weekly earnings between $290 and $659, plus 55% of average weekly earnings between $659 and $1,385, plus 25% of average weekly earnings between $1,385 and $1,923, plus 5% of average weekly earnings between $1,923 and $4,808 (about $250,000 annually).

Qualifying reasons for leave include:

• Welcoming a new child by birth, adoption, or foster care.
• Recovering from a serious illness.
• Caring for a seriously ill family member (by blood or affinity)
• Addressing issues arising from a loved one’s military deployment or serious injury.

What family members could workers take leave to care for?

• Spouses, parents and guardians, and children.
• Siblings, grandparents, and grandchildren; in-laws; and any other association by blood or affinity that is equivalent to a family relationship.

The proposal also allows for three days of paid bereavement leave following the death of an immediate family member. There is currently no national bereavement leave policy.

What does the status quo look like?

The U.S. is the only industrialized nation without a minimum standard of paid family or medical leave, even though universal paid leave enjoys strong public support, including among Republicans. Nine states and DC have paid leave requirements and some employers voluntarily offer these benefits, resulting in a patchwork of policies with varying degrees of generosity. The federal Family and Medical Leave Act (FMLA) requires some employers to provide unpaid time off as well as job protection to eligible employees for family caregiving and medical leave, but just over half (56%) of the workforce is eligible.

Most people will need to take time off work to care for themselves or their families at some point, but only about one in four (23%) workers have access to paid family leave through their employer. That share is even lower for low-wage and part-time workers, and in certain occupations (Figure 1). Data on the share of workers with access to paid medical leave for a longer, serious illness are limited, although 40% of workers are estimated to have access to short-term disability insurance.

How would this proposal intersect with existing state-level and voluntary employer paid leave programs?

The proposed federal bill would allow existing programs to remain so long as they’re at least as comprehensive as the federal program. However, it would apply to a broader range of workers than many employer programs or any of the state-level laws, suggesting that modifications to existing programs could be needed should the federal bill be enacted.

What is the process for Congressional approval?

The Build Back Better Act is being considered through the budget reconciliation process. Passage would require almost all Democrats in the House and all Democrats in the Senate to vote for it.

Some Senators (Republicans and some conservative Democrats) have expressed concern about the overall cost of the budget resolution. While the current version of the entire legislative package is estimated to cost about $3.5 trillion over ten years, it is unclear how the paid leave program, specifically, would be financed and the Congressional Budget Office (CBO) has not scored it. If the price of the current budget resolution gets reduced during Congressional negotiations, the scope of the paid leave provision could be scaled back.

Senate Democrats have not released a recent paid leave proposal but could take up the House bill in its current form or look to elements of other proposals. For example, the paid family and medical leave proposed as part of President Biden’s American Families Plan would cover nearly all workers, would have a $4,000/month cap on wage replacement, and would be financed through general taxes, but it also has not been scored by the CBO. Unlike the House proposal, in Biden’s plan, full benefits would not be realized until year ten of the program. In 2019, the CBO estimated that the Democratic-led FAMILY Act, similar to Biden’s proposal, but partially paid for by a new payroll tax, would cost $547 billion over ten years.

What would universal paid leave mean for women and families?

Paid leave is especially important for women, who are typically the primary caregivers in families, and is associated with improved mental and physical health for new mothers and infants. Research has also found that access to paid family leave helps women remain in the workforce after giving birth.

Additionally, research suggests that under this new proposal, the average American worker taking 12 weeks of paid leave would receive nearly $9,000 of pay.

Enacting universal paid family and medical leave would mean increased federal spending, but would have tangible health and economic benefits for workers and families when they need to take an extended leave for caregiving and medical reasons.

Older adults continue to be one of the populations hardest hit by the coronavirus pandemic. Since the start of the pandemic, people 65 and older have been at greatest risk of hospitalization and death due to COVID-19 compared to other age groups, and represent nearly 80% of all COVID-19 deaths as of September 29, 2021, similar to the rate observed in a July 2020 KFF analysis. At the same time, older adults, among the first groups prioritized to receive the COVID-19 vaccine, have the highest vaccination rate among all age groups, with 83.3% of the 65 and older population fully vaccinated as of September 29, 2021. Vaccination rates for adults 65 and older range from 71.3% in West Virginia to 95.3% in Vermont.

Although cases, hospitalizations and deaths among older adults declined after widespread vaccination efforts began, deaths due to COVID-19 for older adults have recently been on the rise in the U.S. amid the Delta variant outbreak, though not reaching the numbers seen in earlier stages of the pandemic. Recent CDC data show that vaccines remain effective at preventing hospitalizations and deaths. We examined the relationship between vaccination rates as of September 29, 2021 and death rates among adults ages 65 and older during the Delta surge (covering July 1, 2021 through September 25, 2021), by state, based on CDC data for 38 states. This analysis does not include all states due to CDC’s data suppression conventions. (See Methods for additional information.)

Our analysis shows a significant negative correlation between vaccination rates and death rates among older adults during the Delta variant outbreak, with states having lower vaccination rates among adults ages 65 and older experiencing higher death rates among older adults (Figure 1, Table 1).

In the U.S. overall, the death rate was 93 per 100,000 people 65 and older during the study period. In four of the five states with the lowest vaccination rate for older adults – Arkansas, Alabama, Georgia and Nevada – death rates were higher than the national average. For example, in Arkansas, which has a vaccination rate of 72.8%, there were 198 deaths per 100,000 residents 65 and older during the study period. Death rates were similarly high in Alabama (182), Georgia (150), and Nevada (164), where vaccination rates are well below the national average for older adults. The death rate in those four states combined was nearly 2 times the national average. In West Virginia, which has the lowest vaccination rate for people 65 and older (71.3%), the death rate was below the national average at 73 deaths per 100,000 residents.

Conversely, states with the highest vaccination rates for older adults – Wisconsin, Maryland, Minnesota, New Mexico, and Massachusetts – experienced comparatively low death rates among older adults during the Delta surge. For example, in Massachusetts, where 88.8% of older adults have been vaccinated, the death rate was 28 per 100,000 adults 65 and older, a rate about 7 times lower than that of Arkansas during the study period. Other states with comparatively high vaccination rates for older adults and low death rates during the Delta surge include Minnesota (35), Maryland (39) and Wisconsin (48). New Mexico also has one of the highest vaccination rates (89.4%), but there were slightly more deaths among older adults compared to other states during this time period (60 deaths per 100,000). Among the 38 states in this analysis, vaccination rates for people 65 and older range from 71.3% in West Virginia to 90.5% in Wisconsin (Table 1).

Had the death rate in the 10 least vaccinated states been the same as the death rate in the 10 most vaccinated states, there would have been 7,623 fewer deaths among older adults during this period in these 10 states, a 61.7% reduction from the actual number of deaths (12,363). Or, put differently, there were 2.6 times more deaths per 100,000 older adults in the 10 states with lowest vaccination rates than in the 10 states with the highest vaccination rates.

Vaccination rates are a key factor in the number of cases, hospitalizations, and deaths due to COVID-19 occurring during the Delta surge. Other factors could include decreasing vaccine effectiveness over time, which could be a particular concern for older adults during the Delta variant outbreak because much of this group was vaccinated in early 2021, as well as variations in state and local mitigation strategies put in place to address surging rates of infection. Some states implemented mask mandates in certain settings and/or vaccination and testing requirements, while others rejected mandates. For example, Florida – where there has been significant controversy over mask mandates and other restrictions – had the highest death rate for adults 65 and older among all states during this period (230 per 100,000), despite having a higher vaccination rate for adults 65 and older than other states with high death rates.

Substantial variation in vaccination rates and other mitigation strategies at the state level suggests that older adults in some states may face greater risk of death than others in the midst of the ongoing and evolving COVID-19 pandemic. While much of the focus has been on rising cases among children since Delta took hold, cases, hospitalizations, and deaths have been on the rise among older adults. There are signs that cases may be starting to decline in some areas of the country, but death is a lagging indicator, and some areas with recent surges may still see an increase in deaths. With the rollout of boosters for adults 65 and older, we will soon learn whether and when we will see a reversal of these troubling trends for older adults.