In a new Policy Watch, KFF analysts explore the potential impact of the expiration of the American Rescue Plan Act’s enhanced financial help and new eligibility for the Affordable Care Act’s health insurance Marketplace federal subsidies. While the COVID-19 relief legislation passed earlier this year provides greater subsidy assistance through 2022, Democrats in Congress are currently considering making the temporary federal help permanent or extending it as part of their planned budget reconciliation legislation.

The authors describe what is at stake in the current debate, from the additional costs to the federal government if the temporary relief is extended, to premium payments and/or deductibles rising for the millions of people currently receiving enhanced subsidies. The average Marketplace enrollee would see their premiums doubled and would have to pay about $800 more if enrolled the whole year. Low-income people, who are 42% of Marketplace enrollees, pay nothing or a minimal amount in premiums currently and would see the largest percentage increase in premium costs if the subsidies expire.

Also touched on are the potential political implications of the expiration of the enhanced subsidy assistance as Marketplace enrollees would receive their renewal notices in October, 2022, weeks before the midterm congressional elections.

The American Rescue Plan Act (ARPA) passed earlier this year temporarily expanded subsidies available in the Affordable Care Act (ACA) health insurance Marketplaces, building on the ACA’s existing subsidies. Through the end of 2022, low-income families who were already eligible for financial assistance under the ACA are eligible for even more financial help to buy their own health insurance and pay for their copays and deductibles for coverage bought on healthcare.gov or their state’s exchange. Additionally, middle income families who were often priced out of ACA coverage before the ARPA, are now eligible for financial help with their monthly insurance premiums for the first time.

These new and additional subsidies were created under the ARPA as part of a larger pandemic relief strategy, but Democrats have long favored similar strategies to reduce the cost of ACA marketplace plans to enrollees. And the state of California, along with a handful of other states, had already implemented its own state-funded subsidies to address premium affordability. One of the key criticisms of the ACA has been the high and rising premiums, particularly for working families with incomes over four times the poverty level (a little more than $50,000 for a single person or just over $103,000 for a family of four), who previously were not eligible for financial assistance. While the relief package did not directly address high cost-sharing for these enrollees, larger premium subsidies can help them afford plans with lower deductibles.

Now, there is a debate in Congress over whether to make these additional premium subsidies permanent, or at least extend them for a longer time period. On the one hand, if Congress extends the ARPA subsidies or makes them permanent, federal costs would increase. On the other hand, if Congress does not extend these subsidies, premium payments will rise sharply for nearly all marketplace enrollees.

If the ARPA subsidies are extended, federal costs will rise

The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) originally estimated that the additional temporary subsidies provided under the ARPA would increase federal deficits by $34.2 billion. Most of that cost is concentrated in the first couple of years since the additional subsidies expire at the end of 2022, though CBO expected some lingering costs as some subsidized people would remain enrolled for a time, even after the ARPA subsidy enhancements end.

The Department of Health and Human Services (HHS) reports that ARPA subsidies for existing consumers cost $537 million per month. It is likely these costs could rise next year as more people take up coverage during open enrollment.

If subsidies expire, premium payments could double for millions of Marketplace enrollees

According to HHS, the 8 million marketplace enrollees who signed up before the ARPA subsidies were enacted are now paying $68 per month, after accounting for an average monthly premium savings due to the ARPA of $67. Without the ARPA subsidies, premiums would double on average for these enrollees and they would pay an average of $800 per year more if enrolled for the full year.

Premiums or deductibles would increase most steeply for the lowest-income Marketplace enrollees

People with incomes between 1 and 1.5 times the poverty level currently represent 42% of enrollees, and, with the ARPA subsidies, now pay nothing or next to nothing for their monthly premium. Before the ARPA, these individuals had to contribute more than 2% of their income toward the benchmark silver plan premium. These lowest-income enrollees would therefore see the steepest percent increases if ARPA subsidies expire.

Because of these premium increases, some low-income people may move from very generous silver plans with deductibles under $200, to bronze plans with deductibles of about $7,000 – more than 30 times higher. HHS reports that the median deductible in the federal marketplace decreased by more than 90%, from $750 in 2020 to $50 in 2021, because some low-income enrollees moved from bronze to silver plans.

Millions of middle-income people would lose subsidy eligibility

Middle income individuals and families also buy coverage in the marketplace when they don’t have access to job-based group plan coverage. These include people who work for small businesses that don’t offer group health benefits, gig and other self-employed workers, and people who retire early, before the age of Medicare eligibility. We estimate that 3.7 million people (most with incomes between 4 and 6 times poverty) gained subsidy eligibility with the ARPA.

Under the ARPA, the vast majority of people buying their own health insurance coverage can be sheltered from premium increases by taking advantage of the subsidies offered in the ACA marketplace. If these subsidies expire, though, middle and upper-middle income people who lose subsidy eligibility will not only have to make up the difference in the subsidy; they will also be on the hook for any increase in the “sticker price” of the premium between now and January 1, 2023.

Although these individuals earn a living wage, it is often not enough to afford full-priced insurance. A 48-year-old making $60,000 per year would see their monthly premium payments increase by 36% if they lost subsidy eligibility, and that doesn’t account for any additional increase in the sticker price of premiums. Families and older enrollees would see even larger premium increases.

Without a subsidy, a 60-year-old’s health insurance premium currently averages more than $11,000 per year. If that 60-year-old has an income just above $51,000 – over four times the poverty level – their ARPA subsidy covers more than half of their monthly costs. Without the ARPA, their premium would increase 165%.

The timing of potential premium increases could have political implications

In the event ARPA subsidies are allowed to expire, the timing of the resulting impact on insurance affordability could become an election issue. The ARPA premium subsidy enhancements are set to expire at the end of 2022. Open enrollment begins on November 1, just one week before the midterm election is held on November 8, 2022.

For the latest data on U.S. COVID-19 vaccine donations visit our tracker.

There remains a significant gap in vaccine access across the world, with only 2% of the population in low-income countries (LICs) receiving at least one vaccine dose, compared to 30% in lower-middle-income countries (LMICs), 54% in upper-middle-income countries (UMICs), and nearly two-thirds in high-income countries (HICs). One way to address this gap is for countries that have vaccines to donate them to countries in need, either via the multilateral COVAX mechanism or directly to countries and/or regions via bilateral donations. For its part, the U.S. government has pledged to donate at least 1.1 billion doses of COVID-19 vaccine for global use by 2022 and has been delivering doses to countries around the world since June.¹  To understand more about these donated doses and where they have been directed, we analyzed data from the U.S. State Department, COVAX, and other sources. We find that, as of September 20, 2021:

• The U.S. has donated approximately 140 million doses²  to at least 93 countries (see Table 1 and Figure 1). The ten countries receiving the most doses include: Pakistan (15.8 million), Bangladesh (6.5 million), Philippines (6.4 million), Colombia (6.0 million), South Africa (5.7 million), Vietnam (5.0 million), Indonesia (4.5 million), Guatemala (4.5 million), Uzbekistan (4.2 million), and Nigeria (4.0 million).

• Looking by country income, more than half of U.S. doses have been donated to LMICs (see Figure 2). Of the 140 million doses delivered to date, approximately 77 million (55%) have been provided to LMICs, followed by UMICs (36 million, 26%), LICs (10 million, 7%), and HICs (5 million, 4%). When standardized by population, LMICs still account for the largest amount received (24.9 thousand doses per million population), while UMICs and LICs have received smaller amounts (13.5 thousand and 13.3 thousand doses per million population), and HICs receiving the smallest amount with 4.4 thousand doses per million population.

• Countries in the Western Hemisphere have received the most U.S. doses (both in total and when standardized by population size; see Figure 3). Forty million doses (28%) have been provided to countries in the Western Hemisphere, followed by South and Central Asia (35 million, 25%), Sub-Saharan Africa (29 million, 21%), East Asia and the Pacific (29 million, 20%), Middle East and North Africa (4 million, 3%), and Europe and Eurasia (4 million, 3%). When standardized based on population size, the number of doses received by countries in the Western Hemisphere (50.1 thousand per million) is more than double the next largest region (Sub-Saharan Africa; 22.7 thousand doses per million population).

• The Moderna vaccine accounts for the largest share of U.S. donated doses (see Figure 4). Of the 140 million doses provided to date, 42% are Moderna, followed by Pfizer (25%), and Johnson & Johnson (19%).

• The majority of U.S. donated doses have been provided through COVAX (see Figure 5). Approximately 53% of doses (74.7 million) have been provided through COVAX with 38% (54.0 million doses) provided directly to the recipient country.

• The bulk of U.S. COVID-19 vaccine donations occurred in July 2021. By number of deliveries, most occurred in July (64 deliveries or 50%), followed by August (36 deliveries, 28%), June (7 deliveries, 6%), and through September 20 (17 deliveries, 13%). By number of doses delivered, most doses were still delivered in July (82.4 million doses, or 59%), followed by August (17.6 million doses, 13%), through September 20 (14.4 million doses, 10%), and June (12.3 million doses, 9%).

President Biden has said the U.S. will be the “arsenal of vaccines” for the globe, and the 140 million doses donated by the U.S. to date represent one component of the U.S. effort to expand access to Covid-19 vaccines. While the doses provided so far make the U.S. the single largest donor of vaccines worldwide, these donations remain a fraction of what the U.S. has promised to provide by the end of this year and into next and are far from sufficient to meet global needs. Continued monitoring of U.S. donations will help gauge progress toward meeting its global vaccination goals.

1. The U.S. announced in June that it would donate 500 million doses of the Pfizer vaccine, and announced an additional 500 million dose donation of Pfizer vaccine in September; the U.S. plans to supply these Pfizer doses via COVAX. An additional number of Moderna and Johnson & Johnson vaccine doses are part of the 1.1. billion total pledge. The U.S. has stated that all of these doses are to be donated in 2021 and 2022. ↩︎
2. While the U.S. reports that it had shipped over 160 million doses as of September 21, it also reports that it has delivered approximately 140 million doses to country recipients. ↩︎

Prompted by the global COVID-19 Summit, called on by President Biden on September 22 held in conjunction with the United Nations General Assembly (UNGA), we provide updated estimates of global COVID-19 vaccine access and equity (our prior analysis from July is here). We examine access by country income level and region, and also estimate progress toward global vaccination goals. These goals include reaching 40% vaccination coverage in all countries by the end of 2021 and 70% by mid-2022, called for by the World Health Organization and others.¹  In addition, President Biden has called for reaching 70% fully vaccinated in all countries by fall 2022, ahead of next year’s UNGA meeting. For this analysis, we estimate the share of population within each grouping (income and region) expected to receive at least one dose against these targets in order to provide a best-case scenario (since reaching full vaccination would actually require more than one dose for many COVID-19 vaccines).

In our updated analysis we find that, as of September 9, there continue to be wide disparities in access and at current rates, most low-income countries (LICs) and most countries in Africa will not reach global vaccination targets. We also find that, compared to July, the rate at which vaccination would have to increase for LICs to meet global targets is even greater now, due to more ambitious goals and continued low rates of dose administration in these countries.

COVID-19 Vaccinations by Country Income

There are large differences in the share of the population that has received at least one vaccine dose by country income, with low-income countries lagging significantly behind. As of September 9, only 2% of the population in LICs had received at least one vaccine dose, compared to 30% in lower-middle-income countries (LMICs), 54% in upper-middle-income countries (UMICs), and nearly two-thirds (65%) in high-income countries (HICs). In 6 LICs (25%), fewer than 1% had received at least one vaccine dose. By contrast, in 6 HICs (8%), more than 80% of the population had (see Figure 1 and Figure 2).

See Table 1 for the full list of countries in each income group by share of population that has received at least one dose.

Similarly, there is also a large gulf in the rate at which vaccines are being administered by country income. While the daily rate of first doses administered varies by country (see Figure 3), in late August, LMICs surpassed HICs and UMICs, due to both an increase in first doses being administered in LMICs and a decrease in rates among HICs and UMICs. However, all three income groups are vaccinating at a rate ranging from 19-29 times higher than LICs. See Table 2 for a breakdown of countries in each income group by coverage and daily administration rates.

If current trends continue, these disparities are likely to grow, and LICs are unlikely to meet vaccination targets. Based on current vaccination rates (using rates of first doses administered), HICs, UMICs, and LMICs are on track to have 40% or more of their populations having received at least one dose by the end of the year, whereas LICs would need to increase their daily rate by nearly 35 times in order to meet the same goal. HICs, UMICs, and LMICs are also on track to have 70% or more of their populations having received at least one dose by mid-2022, while LICs would need to increase their daily rate by 24 times (see Figure 4). As of September 9, almost all HICs (68 countries or 96%) had already met one or both of the WHO targets, as had just over a third of UMICs (18 or 35%). Less than a fifth of LMICs (9 or 17%) and no LICs had met these targets. In order to reach 70% of the population with at least one dose by next year’s UNGA meeting, LICs would need to increase their daily rate by 19 times.

COVID-19 Vaccinations by Region

As with country income, there are large differences in the share of the population that has received at least one vaccine dose by region, with the highest coverage in the Western Pacific and smallest in Africa. As of September 9, the region with the highest coverage is the Western Pacific (67%) followed by the Americas (56%) and Europe (52%); Africa has the lowest coverage (4%) (see Figure 5 and Figure 6).

See Table 3 for a breakdown of top countries in each region by coverage and daily administration rates.

The rate of vaccine administration is highest in South-East Asia and lowest in Africa. While rates of first doses administered vary by country (see Figure 7), South-East Asia currently has the highest rate of daily doses administered. This region is vaccinating at a rate 1.2 times that of the Western Pacific, 1.4 times that of Eastern Mediterranean nearly 2 times the rate of the Americas, 2.7 times that of Europe, and   6 times higher that of Africa. See Table 4 for a breakdown of countries in each region by coverage and daily administration rates.

These disparities are likely to grow based on current vaccination trends. Western Pacific, Europe, the Americas, and South-East Asia, and Eastern Mediterranean are all ahead of schedule toward reaching 40% by the end of 2021 while Africa would need to increase its rate of daily first doses administered by more than 6 times the current rate. They are also ahead of schedule to reach 70% by mid-2022, while Africa would need to increase its rate of daily first doses administered by approximately 5 times the current rate (see Figure 8). Certain countries, primarily those in Europe, have already met some of these vaccination targets. As of September 9, 35 European countries (66%) have met one or both of these targets, and more than half of countries in the Americas (54%) and the Western Pacific (52%) have met one or both of these targets. On the other hand, only 7% of countries in Africa (3 countries) have met either of these targets. In order to reach 70% of the population with at least one dose by next year’s UNGA meeting, the African region would need to increase its daily rate by nearly 4 times.

Implications

These findings underscore an ongoing equity gap in access to COVID-19 vaccinations around the world, particularly for those living in the poorest countries and in countries in Africa. Furthermore, they suggest that if current rates continue, some of these disparities may grow and many low-income countries will not meet global targets. Increasing vaccine supply and stepping up the pace of vaccinations in those countries lagging furthest behind can narrow the equity gap and help all countries achieve COVID-19 vaccination coverage goals.

Tables

1. While the coverage goals seek to reach 40% and 60% coverage, it is not clear whether this refers to partial coverage (share of population that has received at least one dose) or full coverage (share of population that is fully vaccinated). For our analysis, we focus on share of population that has received at least one dose. Additionally, while these goals aim to vaccinate the global population, we look at populations by income-level and region. ↩︎

Many Medicare beneficiaries face high annual out-of-pocket costs for dental and hearing care — services that generally aren’t covered in traditional Medicare, but typically are covered by Medicare Advantage plans though the scope and value of these benefits vary, finds a new KFF analysis.

The analysis shows that, among beneficiaries who used each type of service, average annual out-of-pocket spending was $914 for hearing care and $874 for dental care in 2018, but considerably less ($230) for vision care. Among those who were in the top 10 percent in terms of their out-of-pocket costs for such services, 2.7 million beneficiaries spent $2,136 or more on their dental care, while 360,000 beneficiaries spent $3,600 or more on hearing services.

Beneficiaries can face high out-of-pocket costs whether they are in traditional Medicare or privately-run Medicare Advantage plans, the analysis finds. Among users of dental services, for instance, average out-of-pocket spending was $766 among beneficiaries in Medicare Advantage and $992 among those in traditional Medicare in 2018.

The analysis also finds that people on Medicare in communities of color, with disabilities, or with low incomes are disproportionately likely to have difficulty getting these services. About 16 percent of all Medicare beneficiaries reported in 2019 that there was a time in the last year that they could not get dental, hearing, or vision care, but this was reported by a greater percentage of beneficiaries under age 65 with long-term disabilities (35%); those enrolled in both Medicare and Medicaid (35%); with low incomes (e.g., 31% for those with income under $10,000); and Black and Hispanic beneficiaries (25% and 22%, respectively).

The new analysis also provides an overview of coverage of dental, hearing, and vision services in Medicare Advantage plans. While most plans offer coverage for these services, the extent of coverage varies and has limits.

• Nearly all Medicare Advantage enrollees with access to dental coverage have preventive care benefits, and most have access to more extensive dental benefits. Cost sharing for more extensive dental services is typically 50 percent for in-network care, and typically is subject to an annual dollar cap on plan payments.
• Similarly, almost all Medicare Advantage enrollees have access to hearing exams and hearing aid coverage. The coverage generally is subject to either a maximum annual dollar cap and/or frequency limits on how often plans cover the service.
• Virtually all Medicare Advantage enrollees have access to vision exams and eyewear coverage, typically subject to maximum annual limits averaging about $160 per year.

The findings come as policymakers in Congress are considering adding dental, hearing, and vision benefits to Medicare as part of the budget reconciliation bill, one of several competing spending priorities in the debate. It would be the largest expansion of Medicare benefits since the Part D drug benefit was launched in 2006. (A similar 2019 proposal would have increased Medicare spending by more than $300 billion over 10 years according to the Congressional Budget Office.)

For the full analysis and other KFF data and analyses about Medicare, including the recent Medicare and Dental Coverage: A Closer Look, visit kff.org

Notably missing among covered benefits for older adults and people with long-term disabilities who have Medicare coverage are dental, hearing, and vision services, except under limited circumstances. Results from a recent KFF poll indicate that 90% of the public says expanding Medicare to include dental, hearing, vision is a “top” or “important” priority for Congress. Policymakers are proposing to add coverage for these services as part of budget reconciliation legislation, and a provision to add these benefits to traditional Medicare was included in the version of H.R. 3 that passed the House of Representatives in the 116^th Congress.

The Biden Administration endorsed improving access to these benefits for Medicare beneficiaries in the FY2022 budget. Addressing these gaps in Medicare benefits is grounded in a substantial body of research showing that untreated dental, vision, and hearing problems can have negative physical and mental health consequences. Adding these benefits to Medicare would increase federal spending, and they will be competing against other priorities in the budget reconciliation debate.

Dental, hearing, and vision services are typically offered by Medicare Advantage plans, but the extent of that coverage and the value of these benefits varies. Some beneficiaries in traditional Medicare may have private coverage or coverage through Medicaid for these services, but many do not. As a result, beneficiaries who need dental, vision, or hearing care may forego getting the care or treatment they need or face out-of-pocket costs that can run into the hundreds and even thousands of dollars for expensive dental treatment, hearing aids, or corrective eyewear.

In a separate KFF analysis, we analyzed dental coverage, use, and out-of-pocket spending among Medicare beneficiaries and provided an in-depth look at coverage of dental services in Medicare Advantage plans. In this brief, we build on our prior work by analyzing hearing and vision use, out-of-pocket spending and cost-related barriers to care among beneficiaries in traditional Medicare and Medicare Advantage, incorporating top-level findings from our analysis of dental services to provide a comprehensive profile of dental, hearing, and vision benefits in Medicare Advantage plans. The analysis of spending, use, and cost-related barriers to care is based on self-reported data by beneficiaries in both traditional Medicare and Medicare Advantage from the 2018 and 2019 Medicare Current Beneficiary Survey, and analysis of Medicare Advantage plan benefits is based on the 2021 Medicare Advantage Enrollment and Benefit files for data on individual Medicare Advantage plans (see Methods for details).

Findings

Dental, Hearing, and Vision Use and Spending

• Difficulty with hearing and vision is relatively common among Medicare beneficiaries, with close to half (44%, or 25.9 million) of beneficiaries reporting difficulty hearing and more than one third (35% or 20.2 million beneficiaries) reporting difficulty seeing in 2019. These percentages may understate the share of beneficiaries who have problems with hearing or vision in that some beneficiaries who wear corrective eyewear or hearing aids do not report having difficulties. For example, among the 83% of Medicare beneficiaries who report wearing eyeglasses or contact lenses, only 32% say they have vision difficulties, while of the 14% of beneficiaries who report using a hearing aid, 65% say they have hearing difficulties. The lower overall rate of hearing aid use, relative to the rate of reported hearing difficulties, may be a function of affordability, considering the relatively high cost of hearing aids and limited availability of lower-cost options for hearing technology.
• A larger share of Medicare beneficiaries used dental services than either hearing or vision services in 2018. In 2018, 53% (31.3 million) of beneficiaries reported having a dental visit within the past year, 35% (20.3 million) used vision services, and 8% (4.6 million) used hearing services (Figure 1).
• On average, out-of-pocket spending on hearing and dental care by Medicare beneficiaries who used these services in 2018 was higher than spending on vision care by beneficiaries who used vision services that year. Among beneficiaries who used each type of service, average spending was $914 for hearing care, $874 for dental care, and $230 for vision care (Figure 1).

• The distribution of out-of-pocket spending on dental and hearing services is highly skewed, with a small share of users incurring significant out-of-pocket costs (likely associated with the purchase of costly equipment such as hearing aids, or expensive dental procedures, such as implants). For example, in 2018, among beneficiaries who used dental services, beneficiaries in the top 10% in terms of their out-of-pocket costs (2.7 million beneficiaries) spent $2,136 or more on their dental care, while among beneficiaries who used hearing services, beneficiaries in the top 10% in terms of out-of-pocket costs (0.4 million beneficiaries) spent $3,600 or more on these services (Figure 2). Conversely, half of beneficiaries who used dental services had out-of-pocket spending below $244 for their dental care; half of those who used vision services had out-of-pocket spending below $130 for their vision care; and half of those who used hearing services had out-of-pocket spending below $60 for their hearing care.

• Among users of these services, beneficiaries enrolled in Medicare Advantage plans spent less out of pocket for dental and vision care than beneficiaries in traditional Medicare in 2018, but there was no difference between the two groups in spending on hearing care. Both groups spent substantially more for dental and hearing services than vision services. For dental services, average out-of-pocket spending was $766 among beneficiaries in Medicare Advantage and $992 among beneficiaries in traditional Medicare (Figure 3). For vision services, average out-of-pocket spending was $194 among beneficiaries in Medicare Advantage and $242 among beneficiaries in traditional Medicare. Most Medicare Advantage enrollees had coverage for some dental, vision and hearing benefits, as described below, but still incurred out-of-pocket costs for these services.
  • Lower average out-of-pocket spending among Medicare Advantage enrollees for dental and vision care is likely due to several factors. Most Medicare Advantage enrollees have coverage for dental, hearing, and vision services through their plan (as described below), which helps to improve the affordability of these services. Lower out-of-pocket spending among Medicare Advantage enrollees may also be related to lower overall income levels among these beneficiaries. Previous KFF analysis showed that average out-of-pocket spending on dental care rises with income because higher income beneficiaries are more able to afford such expenses, not because they have greater dental needs. It is possible that some traditional Medicare beneficiaries used more, or more expensive, types of dental and vision care than those in Medicare Advantage, contributing to their higher average out-of-pocket costs for these services. Due to data limitations, it is not possible to assess how utilization of dental, vision, or hearing care differed between Medicare Advantage and traditional Medicare enrollees.

• About one in six Medicare beneficiaries reported in 2019 that there was a time in the last year that they could not get dental, hearing, or vision care, and among those who reported access problems, cost was a major barrier.
  • Overall, in 2019, 16% of Medicare beneficiaries, or 9.5 million, reported that there was a time in the last year that they could not get dental, hearing, or vision care. This includes 12% of Medicare beneficiaries who said they could not get dental care, 6% who couldn’t get vision care, and 3% who couldn’t get hearing care (Figure 4).
  • Similar shares of beneficiaries in both traditional Medicare and Medicare Advantage reported access problems in the last year for dental, hearing, or vision services (16% and 17%, respectively).
  • Among the 20.2 million beneficiaries who reported difficulty seeing, 11% (2.1 million beneficiaries) said there was a time in the last year they could not get vision care, and among the 25.9 million beneficiaries who reported difficulty hearing, 7% (1.8 million beneficiaries) said there was a time in the last year they could not get hearing care.
  • Medicare beneficiaries more likely to report difficulty getting dental, hearing, or vision care include beneficiaries under age 65 with long-term disabilities (35%); with low incomes (e.g., 31% for those with income under $10,000); in fair or poor health (30%); enrolled in both Medicare and Medicaid (35%); Black and Hispanic beneficiaries (25% and 22%, respectively); and residing in rural areas (20%) (Figure 5).

• Among the 16% of beneficiaries who said that there was a time in the last year that they could not get dental, hearing, or vision care, a majority (70%) said that it was due to cost (Figure 4). This includes 75% of those who couldn’t get hearing care, 71% of those who couldn’t get dental care, and 66% of those who couldn’t get vision care.
  • Among beneficiaries in traditional Medicare and Medicare Advantage who reported access problems in the last year for dental, hearing, or vision care, roughly 7 in 10 beneficiaries in both groups said that cost was a barrier to getting these services (72% and 70%, respectively).
  • Beneficiaries more likely to report cost as a barrier to dental, hearing, or vision care include those under age 65 with long-term disabilities (76%); with low incomes (e.g., 72% for those with incomes under $10,000); and in fair/poor health (75%).

What Dental, Hearing, and Vision Benefits Are Offered by Medicare Advantage Plans?

Most Medicare Advantage plans provide some coverage of routine dental, vision, and hearing benefits, unlike traditional Medicare. Plans can use rebate dollars – a portion of the difference between their bid to cover Medicare Parts A and B services and the benchmark – to provide supplemental benefits, such as dental, hearing, and vision benefits. Plans also use rebate dollars to lower enrollee cost sharing and reduce premiums, and for administrative expenses and profit. According to MedPAC, about 21% of rebate dollars in 2021, or $29 per enrollee per month, were used to cover supplemental benefits not covered by traditional Medicare.

Dental Benefits

In 2021, 94% of Medicare Advantage enrollees or 16.6 million people, are in a plan that offers access to some dental coverage. Virtually all Medicare Advantage enrollees have access to preventive dental benefits and most have access to more extensive dental benefits, according to a prior KFF analysis. Most enrollees with access to more extensive benefits are typically subject to annual dollar limits on coverage, which averages $1,300.

Among Medicare Advantage enrollees with access to dental coverage:

• Most (86%) of these enrollees are offered both preventive and more extensive dental benefits.
• More than three in four (78%) Medicare Advantage enrollees who are offered more extensive coverage are in plans with annual dollar limits on dental coverage, with an average limit of $1,300 in 2021. More than half (59%) of these enrollees are in a plan with a maximum dental benefit of $1,000 or less.
• Nearly two-thirds of Medicare Advantage enrollees (64%) with access to preventive benefits, such as oral exams, cleanings, and/or x-rays, pay no cost sharing for these services, though their coverage is typically subject to an annual dollar cap. The most common coinsurance for more extensive dental services, such as fillings, extractions, and root canals, is 50%.
• About 10% of Medicare Advantage beneficiaries are required to pay a separate premium to access any dental benefits. For additional and more detailed information about dental benefits offered by Medicare Advantage plans, see “Medicare and Dental Coverage: A Closer Look.”

Hearing Benefits

In 2021, 97% of Medicare Advantage enrollees or 17.1 million people, have access to a hearing benefit. Among these enrollees, virtually all (95%) are in plans that provide access to both hearing exams and hearing aids (either outer ear, inner ear, or over the ear). Hearing aid coverage is typically subject to annual dollar limits on coverage or frequency limits, with an average dollar limit of $960 and the most common frequency limit of one set of aids per year.

Among Medicare Advantage enrollees who have access to hearing coverage:

• Virtually everyone with hearing aid coverage is subject to either annual dollar limits on coverage, frequency limits on covered services, or both (Figure 6).
  • Nearly a third (32%) of Medicare Advantage enrollees are in plans with a maximum dollar limit the plan will pay annually toward hearing aid coverage as well as frequency limits on hearing aid coverage; about 8% are in plans with maximum dollar limits, but do not have frequency limits. For those in plans with maximum annual dollar limits, the average limit is $960 in 2021, ranging from $66 up to $4,000.
  • Nearly 6 in 10 enrollees (59%) are in plans that do not have maximum dollar limits on hearing aid coverage but do have a frequency limit on how often hearing aids are covered; 1% of enrollees have neither a maximum annual dollar limit nor a frequency limit on hearing aids.

• Medicare Advantage enrollees are often subject to limits in the frequency of obtaining certain covered hearing-related services.
  • Among enrollees with access to hearing exams, virtually all enrollees (98%) are in plans that limit the number of hearing exams, with the most common limit being no more than once per year.
  • Of the 69% of enrollees with access to fitting and evaluation for hearing aids, about 88% are in plans that have frequency limits on those services, with the most common limit being no more than once per year.
  • Most enrollees (91%) are in plans with frequency limits on the number of hearing aids they can receive in a given period. The most common limit is one set (one for each ear) per year (58%), followed by one set every two years (28%), and one set every three years (14%).
• Hearing exams are often covered without cost sharing, but hearing aids are typically subject to cost-sharing requirements, and enrollees who do not face cost sharing for hearing aids are usually subject to annual dollar limits.
  • Nearly three quarters of all enrollees (74%) are in plans that do not require cost sharing for hearing exams, while 11% of enrollees are in plans that report cost sharing for hearing exams, with the majority being copays, which range from $15 to $50. Data on cost sharing is missing for plans that cover the remaining 15% of enrollees (see Methods for more information).
  • Of those enrollees with access to fitting and evaluations of hearing aids as part of their plan, more than half (61%) of enrollees are in plans that do not require cost sharing for these services. About 5% of enrollees are in plans that require cost sharing for fittings and evaluations, nearly all copays, which range from $15 to $50.
  • About 60% of enrollees are in plans that require cost sharing for hearing aids, which can range from $5 up to $3,355. Nearly one quarter of enrollees (22%) pay no cost sharing for any type of hearing aid, but virtually all these enrollees are in plans with a maximum annual limit.

Vision Benefits

In 2021, 99% of Medicare Advantage enrollees or 17.5 million people, have access to some vision coverage. Among these enrollees, virtually all (93%) are in plans that provide access to both eye exams and eyewear (contacts and/or eyeglasses). Most enrollees do not pay cost sharing for eyewear, but nearly all vision coverage is subject to annual dollar limits on coverage, averaging $160.

Among Medicare Advantage enrollees who have access to vision coverage:

• Virtually all (99%) Medicare Advantage enrollees offered both eye exams and eyewear coverage are in plans with annual dollar limits on vision coverage, with an average limit of $160 in 2021. Nearly half (45%) of these enrollees are in a plan with a maximum vision care benefit of $100 or less (Figure 7).

• For vision benefits, Medicare Advantage enrollees are often limited in terms of the frequency of obtaining certain covered services.
  • Among enrollees with access to eye exams, nearly all enrollees (94%) are in plans that limit the number of covered eye exams, with the most common limit being no more than once per year.
  • More than half of enrollees (58%) in plans that cover eyeglasses are limited in how often they can get a new pair. Among those with a limit on eyeglasses, the most common limit is one pair per year (52%), followed by one pair every two years (47%).
  • Among plans that cover contact lenses, one third of enrollees (33%) are in plans that have frequency limits on contact lenses, typically once per year.
  • Virtually all enrollees in plans without quantity limits on eyeglasses or contact lenses are limited by an annual dollar cap, as noted above.
• Vision exams are often covered without cost sharing, and eyewear is also often covered without cost sharing but is always subject to annual dollar limits.
  • Most enrollees (71%) pay no cost sharing for eye exams, while about 14% of enrollees are in plans that report cost sharing for eye exams, with virtually all requiring copays, ranging from $5 to $20. Data on cost sharing is missing for plans that cover the remaining 15% of enrollees.
  • Around two-thirds of Medicare Advantage enrollees pay no cost sharing for eyeglasses or contact lenses (66% and 64% respectively), but all these enrollees are in plans that have an annual maximum dollar limit on coverage. About 2% of enrollees are in plans that require cost sharing for either eyeglasses or contacts, with nearly all requiring copays; these enrollees are also subject to an annual dollar cap.

In conducting this analysis of Medicare Advantage benefits, we found that plans do not use standard language when defining their benefits and include varying levels of detail, making it challenging for consumers or researchers to compare the scope of covered benefits across plans. Our analyses take into account benefits, as described in the Medicare Advantage Plan Benefit files, which includes annual limits on plan benefits, frequency limits on obtaining covered services, and cost-sharing requirements, but does not take into account plan restrictions that may affect access, such as type or model of hearing aids covered, type of eyeglasses or lenses covered (e.g. bifocals, graduated lenses), the extent to which prior authorization rules are imposed, or network restrictions on suppliers.

Discussion

While some Medicare beneficiaries have insurance that helps cover some dental, hearing, and vision expenses (such as Medicare Advantage plans), the scope of that coverage is often limited, leading many on Medicare to pay out-of-pocket or forego the help they need due to costs. Traditional Medicare generally does not cover routine dental, hearing, or vision services, and coverage for these services under Medicare Advantage varies.

Based on self-reported data, use of dental, hearing, and vision services ranges widely among Medicare beneficiaries overall, with just over half of all beneficiaries reporting that they used dental services in 2018, roughly one-third using vision services, and fewer than one in 10 using hearing services. While it is not the case that use of these services is indicated or required annually for everyone on Medicare, our analysis shows that vision and hearing difficulty is not uncommon among Medicare beneficiaries and cost prevented many beneficiaries in both traditional Medicare and Medicare Advantage plans who sought dental, hearing, or vision care from getting it in 2019.

Medicare Advantage plans are the leading source of dental coverage for people with Medicare, and a main source of coverage for hearing and vision. According to our analysis of plan benefit data, most Medicare Advantage plans provide access to these benefits; only 6% of enrollees are in plans that do not cover dental benefits, 3% are in plans that do not cover hearing exams and/or aids, and 1% are in plans that do not cover eye exams/glasses. While the scope of coverage varies across Medicare Advantage plans, there are some common features within each category. Nearly all Medicare Advantage enrollees with access to dental coverage have preventive benefits, and most have access to more extensive dental benefits, though cost sharing for more extensive services is typically 50% for in-network care, and subject to an annual cap on plan payments. Almost all Medicare Advantage enrollees have access to both hearing exams and hearing aid coverage; hearing aid coverage is subject to either a maximum annual dollar cap and/or frequency limits on how often plans cover the service. Virtually all Medicare Advantage enrollees have access to both vision exams and eyewear coverage, and this coverage is typically subject to maximum annual limits, averaging about $160 per year.

Policymakers are considering adding dental, hearing, and vision benefits to Medicare as part of the budget reconciliation bill – a change that would be the largest expansion of Medicare benefits since the Part D drug benefit was launched in 2006. These program improvements would lead to higher federal spending of $358 billion over 10 years (2020-2029), including $238 billion for dental and oral health care, $89 billion for hearing care, and $30.1 billion for vision care, according to a Congressional Budget Office estimate of the version of H.R.3 passed by the House in 2019. Additionally, in a July 2021 executive order, President Biden called for the Secretary of Health and Human Services to issue a proposed rule that would allow hearing aids to be sold over-the-counter, as allowed under the FDA Reauthorization Act of 2017 – a move that could help make hearing aids more affordable for people with hearing difficulties who may be foregoing purchasing them due to cost. Expanding Medicare coverage for dental, hearing, and vision services and making lower-cost hearing aids available would address significant gaps in coverage and could alleviate cost concerns related to these services for people on Medicare.

The health and economic effects of the pandemic have significant implications for Medicaid.  Medicaid, which provides coverage of health and long-term care for low-income residents, is administered by states within broad federal rules and jointly funded by states and the federal government. Medicaid is a counter-cyclical program, meaning that more people become eligible and enroll during economic downturns; at the same time, states may face declines in revenues that make it difficult to fund the state share of funding for the program. As in past economic downturns, the federal government has provided additional financial assistance to states during the current pandemic to help them maintain their Medicaid programs at a time of growing need.  This brief presents the most current data for key indicators to help understand how various economic factors that could affect Medicaid enrollment and spending are changing in light of the pandemic as well as efforts to address the pandemic and the start of economic recovery.  An overview of the methods is in the Methods Box at the end of the brief, and a companion brief provides an overview of Medicaid Financing Basics.

What factors could affect Medicaid enrollment?

Medicaid enrollment is typically the primary driver of spending.  Administrative data for Medicaid show that after declines in enrollment from 2017 through 2019, total enrollment nationwide began to grow after February 2020, right before the pandemic began. Between February 2020 and April 2021, enrollment steadily increased to 82.3 million, an increase of 11.1 million, or 15.5%, from actual enrollment in February 2020. These trends in enrollment likely reflect changes in the economy as more people experience income and job loss and become eligible and enroll in Medicaid coverage as well as “maintenance of eligibility” (MOE) provisions in the Families First Coronavirus Response Act (FFCRA) that require states to ensure continuous coverage to current Medicaid enrollees to access a temporary increase in the federal Medicaid match rate.

Key economic indicators that could signal changes to Medicaid enrollment include those showing job and income loss such as the unemployment rate, unemployment insurance claims, and the employment-to-population ratio.  Unemployment rates and unemployment insurance filings capture people who are actively looking for or have recently lost employment, respectively, and may be affected by people who opt to leave the workforce altogether.  Employment-to-population ratios capture what share of the population is working overall.  All measures capture some aspect of income loss, which could make more people eligible for Medicaid. However, Medicaid enrollment changes may lag behind changes in broader economic metrics.  For example, when unemployment rises, increases in Medicaid enrollment may follow, but improvements in unemployment may not immediately translate to slower Medicaid growth. This effect was observed following the end of the Great Recession in 2009 when Medicaid spending and enrollment continued to grow in 2010 and 2011 and is due in part by MOE provisions that prevent states that accept additional federal funding from disenrolling Medicaid beneficiaries.

National data show sharp increases in the average unemployment rate and unemployment claims following the onset of the pandemic in March 2020, but they have moderated in more recent months.  Indicators of employment-to-population ratios also show precipitous declines at the start of the pandemic, unmatched by trends since 2008. While changes in indicators related to employment and jobs have moderated in more recent months, they are still not at pre-pandemic levels. For example, July 2021 saw a national unemployment rate of 5.4% across all states including DC, below the peak of 14.8% in April 2020 but still above 3.5% in February 2020, right before the pandemic.  Similarly, total unemployment claims peaked in May 2020 and have been steadily declining, but total claims in July 2021 were greater than February 2020.  Finally, the employment-to-population ratio dropped to a low of 51.3% in April 2020; the 58.4% ratio in July 2021 is below the February 2020 level of 61.1%.  Unemployment rates and unemployment claims were higher, and the employment-to-population ratios were lower relative to the Great Recession that started in December 2007.

For each employment indicator there was wide variation across states in the average over the most recent 12-month period compared to a year earlier.  Looking at the average for the most recent 12-month period (August 2020 to July 2021) compared to the same period in the prior year, the national unemployment rate decreased by 1%; however, growth across states varied significantly, from more than a 30% increase in Hawaii and Connecticut to a 33% decrease in New Hampshire. Measures continue to improve, with over half of states seeing declines in their average unemployment rate and number of unemployment claims and a quarter of states seeing growth in their average employment-to-population ratio when comparing the most recent 12-month average to the year prior. South Dakota was in the top 5 states with the most improvement in its 12-month average for at least two of the three indicators, and Connecticut, D.C., Hawaii, and Maryland were hardest hit, being in the top 5 with the largest changes in their 12-month averages for at least two of the three indicators.

Employment-related economic consequences are directly related to the proportion of jobs a state has in more impacted sectors. States, like Hawaii and Nevada, which rely heavily on more exposed sectors (restaurants and bars, travel and transportation, entertainment, etc.), saw larger changes in job-related indicators throughout the pandemic. On the other hand, states more reliant on less exposed sectors, like agriculture in the Midwestern states, fared better. The leisure and hospitality industries experienced the highest unemployment rates at the start of the pandemic, but other industries also reliant on in-person work, like mining, are now seeing higher rates of unemployment. Many individuals enrolled in Medicaid even before the pandemic are employed in exposed sectors (such as food and other service industries) and are particularly at risk for income or job loss. Additionally, state issued stay-at-home orders and personal social-distancing behaviors varied across states and also contributed decreased economic activity.

What factors could affect states’ ability to finance Medicaid?

States generally fund their share of Medicaid costs through general revenue collected from residents, businesses, and sales taxes. States must adopt balanced budgets, so during economic downturns when demand for services and programs like Medicaid increases, state revenues typically decline, putting pressure on state budgets.  To provide broad fiscal relief to states and to help support increases in Medicaid enrollment, the Families First Coronavirus Response Act (FFCRA) authorized a 6.2 percentage point increase in the federal match rate (“FMAP”) for states that meet certain “maintenance of eligibility” (MOE) requirements. The additional funds were retroactively available to states beginning January 1, 2020 and continue through the quarter in which the PHE period ends. While the current PHE declaration expires 90 days from July 20, 2021, the Biden Administration has notified states that the PHE will likely remain in place throughout CY 2021 and that states will receive 60 days-notice before the end of the PHE.

Measures of changes in state revenue can provide insight into states’ ability to finance the state share of Medicaid. State revenues are largely dependent on revenue from personal income taxes, corporate income taxes and sales taxes. The share of revenue coming from each of these sources varies, and 9 states have no personal income tax at all. In addition, each type of tax may be affected differently by changes in economic conditions.

State revenues overall have increased sharply in recent months, with unadjusted 12-month rolling averages for revenue now surpassing pre-pandemic averages. For the most recent 12-month rolling average (ending June 2021) compared to the 12-month average from February 2020, before the pandemic, average monthly total revenues are 13.4% higher. This is much improved from the 12-month period ending June 2020, the lowest point during the pandemic, which saw a 8.0% drop from the 12-month average from February 2020. Overall, states have not experienced revenue declines as large as original projections. While the data show steep revenue declines early in the pandemic, overall unadjusted revenues have rebounded in recent months, though some of the sharp increases in the recent 12-month rolling averages can be attributed to delayed income tax filing deadlines. Revenues appear to have surpassed pre-pandemic levels; however, there is variation across states, and the data pre-dates the Delta variant and is volatile due to changing income tax deadlines. States adapted to the changing outlook, adopting conservative FY 2021 budgets and then adopting FY 2022 budgets with increases in state spending and revenue after ending FY 2021 with surpluses.

State revenue changes vary across revenue sources, with personal income taxes faring better than sales taxes during the pandemic. Corporate income tax revenues are volatile and can fluctuate considerably from month to month. For the most recent 12-month rolling average (ending June 2021) compared to February 2020, before the pandemic, average monthly personal income taxes increased by 19.5%, corporate income taxes grew by 40.4%, and sales taxes grew by 6.3%. Most states pushed back their 2020 income tax filing deadline from April 15^th to July 15^th and their 2021 deadline to May 17^th, delaying income tax revenue and causing the 12-month averages for May and June 2021 to contain two income tax collection months for many states. US total data is preliminary for April, May, and June 2021, due to delays by some states to report revenues as they close out the 2021 fiscal year.

There is considerable variation across states with regard to changes in revenues. Almost all states are now seeing an increase in average monthly total tax revenue for the most recent 12-month period (ending June 2021) compared to the prior year, with only 2 states experiencing declines. Changes in overall average monthly tax collections ranged from a decline of 18% in Alaska to growth of 53% in California for the most recent 12-month period compared to the prior year, and there was also variation by revenue source. Since the pandemic has disproportionately affected low income workers in the service industry, most states experienced smaller declines in personal income tax revenue than expected, especially for states with progressive income tax structures, where people with higher incomes pay a higher share of income tax.  In addition, income tax withholdings on the supplemental federal unemployment benefits may have also sustained state income tax revenues.

States that issued stay-at-home orders saw reduced sales tax revenues, and states that rely heavily on tourism, like Hawaii, Florida, and Nevada, or oil and gas, like Alaska and North Dakota, experienced larger revenue declines.  Sales tax revenues were bolstered by $600 weekly federal unemployment benefits under the CARES Act that allowed consumers to continue spending, the 2018 Supreme Court decision that authorized states to collect sales tax on online purchases, and increased spending on goods instead of services, which most states do not tax. While sales taxes on groceries have been shown to worsen income and racial inequalities, states that tax groceries saw smaller declines in sales tax revenue during the pandemic. Sales tax revenues are recovering more slowly than personal income and corporate income tax revenues, and states that rely more heavily on sales tax revenues and do not have an income tax experienced steeper declines in total tax revenues.

Looking Ahead

The ongoing health and economic effects of the pandemic will continue to have implications for Medicaid enrollment and financing. While revenues and employment indicators have improved, employment indicators have not yet returned to pre-pandemic levels and there remains a lot of variation across states. In addition, while indicators are improving on average across states, it is unclear how quickly and how much jobs and revenue in certain sectors of the economy will improve.  As the economy improves, what happens in certain sectors could greatly affect Medicaid as there have been disproportionate effects on low-wage workers who could be eligible for Medicaid.

Almost all states have adopted budgets for state fiscal year 2022 (which started July 1 for most states), and revenue and spending projections incorporated improvements in revenue tied to COVID-19 vaccination efforts and eased restrictions, assumptions about the duration of the PHE (which has implications for the temporary fiscal relief and continuous coverage requirements for Medicaid), and federal stimulus funds that were part of the American Rescue Plan. However, the spread of the Delta variant and the recent surge in COVID-19 cases and deaths casts more uncertainty about state economic conditions and the duration of the PHE.