Home and community-based services (HCBS) help seniors and people with disabilities and chronic illnesses live independently outside institutions by assisting with daily needs. HCBS include but are not limited to home health aide services, assistance with self-care tasks such as eating or bathing, supportive housing, and assistive technology. People who use HCBS include seniors with physical and/or cognitive limitations, people with intellectual disabilities such as Down’s syndrome or autism, people with physical disabilities such as spinal cord injuries or cerebral palsy, people with serious mental illness, and people with disabling chronic conditions.

The unmet need for HCBS for seniors and people with disabilities pre-dates the COVID-19 pandemic, with Medicaid serving as the primary source of coverage for HCBS. These services are unaffordable out-of-pocket for many people and unavailable through private insurance or Medicare. The pandemic’s disproportionate impact on seniors and people with disabilities, particularly those living in congregate settings such as nursing homes, has brought heightened focus on the need for additional HCBS, and the growing elderly population in the coming years will further intensify the need for these services. Over the last several decades, states have focused on shifting the Medicaid program’s historical bias toward institutional services by devoting an increasing share of their total long-term services and supports (LTSS) spending to HCBS. Spending on HCBS surpassed spending on institutional care for the first time in FY 2013 and comprised 56% of total Medicaid LTSS spending in FY 2018, with substantial variation among states.

The American Rescue Plan, the COVID relief package recently signed into law by President Biden, includes a provision to increase the federal matching rate (FMAP) for spending on Medicaid HCBS by 10 percentage points from April 1, 2021 through March 31, 2022 provided states maintain state spending levels as of April 1, 2021. To access the new funds, recent guidance requires states to submit for CMS approval an initial HCBS spending plan projection and narrative by June 12, 2021, though CMS recently announced that states could request a 30-day extension for their initial submission due date. This brief discusses the new provision and provides state by state estimates of the potential effects of the policy change.

What does the American Rescue Plan do for HCBS?

The HCBS provision in the American Rescue Plan increases the federal matching rate (FMAP) for Medicaid HCBS spending by 10 percentage points from April 1, 2021 through March 31, 2022. The law specifies that states must use the enhanced funds to “implement, or supplement the implementation of, one or more activities to enhance, expand, or strengthen” Medicaid HCBS. CMS guidance released on May 13, 2021 confirms that the enhanced funds must be used for activities “beyond what is available under the [state’s] Medicaid program as of April 1, 2021.” While the final version of the law did not detail specific activities, the CMS guidance provides a non-exhaustive list of initiatives that states might fund, including activities to meet HCBS needs created by COVID-19 and activities to build state HCBS capacity and advance LTSS rebalancing reforms. For example, in response to COVID-19, states might use the enhanced funds to expand covered services to reduce the risk of institutionalization, facilitate COVID-19 vaccine access for HCBS enrollees, or support the direct care workforce. To build HCBS capacity and advance LTSS rebalancing, states might streamline eligibility and enrollment processes, increase covered services, expand the direct care workforce, or serve additional HCBS enrollees. (Figure 1). States have until March 31, 2024 to spend the enhanced funds. The Appendix Table contains a detailed summary of the activities included in the CMS guidance.

The law increases the total dollars available for Medicaid HCBS, as states are required to maintain their current HCBS spending to qualify for the enhanced federal funds. Specifically, states must maintain their level of HCBS spending as of April 1, 2021. CMS guidance confirms that states “cannot use state funds equivalent to the amount of federal funds made available by the increased FMAP to pay for HCBS that [are] available under the[ir] Medicaid program as of April 1, 2021.” The Appendix provides more detail about the conditions states must meet to satisfy this requirement according to CMS guidance. The proposed 10 percentage point increase for HCBS will be added to the state’s regular Medicaid matching rate (which ranges from 50% to 78% in FY 2022), as well as to other FMAP increases available to states, including the 6 percentage point increase for Community First Choice attendant care services, the 6.2 percentage point increase provided to address the COVID-19 public health emergency (PHE) under the Families First Coronavirus Response Act, any disaster recovery FMAP (available to states with a federally declared disaster and a certain amount of FMAP decline), and the 90% federal matching rate for Medicaid expansion adults under the ACA, as well as the new 5 percentage point increase in the regular matching rate for states newly adopting the ACA expansion provided in a separate section of the law. The cumulative enhanced matching rate for Medicaid HCBS under the law is capped at 95%.

What is the estimated effect of the American Rescue Plan HCBS funding for states?

We estimate that nationally, federal spending for HCBS could increase by about $11.4 billion (Table 1). This estimate is similar to that put out by the Congressional Budget Office, which estimated increased federal costs of approximately $12.7 billion. In the time period that the FMAP increase would be in effect (the final two quarters of FY 2021 and the first two quarters of FY 2022), we estimate that total federal and state Medicaid HCBS spending will be approximately $114 billion (Table 1). Estimated total Medicaid HCBS spending varies widely by state, ranging from $198 million dollars in Wyoming to nearly $22 billion in California. The additional $11.4 billion federal dollars from this FMAP increase would be distributed proportional to the size of state HCBS programs, with California receiving nearly $2.2 billion additional federal dollars and Wyoming receiving about $19.8 million additional federal dollars. This wide state variation reflects both state size and various state policy choices on HCBS programs, nearly all of which are offered at state option.

These estimates are made with a degree of uncertainly. Our estimates reflect HCBS spending in FY 2021 and FY 2022 based on inflation rates from CBO’s projected spending on Medicaid LTSS. However, these estimates do not account for states expanding underlying HCBS spending beyond current levels due to the additional federal incentive. Additionally, some spending in some states may not be eligible for the full increase, should the state hit the 95% federal match cap, after accounting for the 10 percentage point increase in the bill as well as other enhanced matching rates available to states, such as the enhanced match for the ACA Medicaid expansion group. These estimates assume that all states maintain their current spending levels, as required by the law.

 

CMS’s May 2021 guidance adopts a three-pronged maintenance of effort requirement for states to demonstrate that they are using the new federal funds to supplement and not supplant existing state spending as required by the American Rescue Plan. Specifically, states must (1) not impose eligibility standards, methodologies or procedures for HCBS programs and services stricter than those in effect on April 1, 2021; (2) maintain coverage of HCBS and the amount, duration, and scope of those services as of April 1, 2021; and (3) not decrease provider payments below the rate in effect on April 1, 2021.

The guidance provides that states must maintain any temporary changes to HCBS eligibility, services, or provider payment adopted under Medicaid emergency authorities in response to the COVID-19 PHE “for as long as allowable under those authorities.” However, CMS clarifies that, to meet the requirements to receive the enhanced HCBS FMAP, states do not have to retain such changes past the approved end date of any emergency authorities. CMS also notes that states will not be penalized for fluctuations in HCBS enrollment, utilization, or spending that are unrelated to changes in state policies and procedures, especially during the COVID-19 PHE.

The state’s initial HCBS spending plan projection and narrative should estimate the total amount of enhanced funds that the state anticipates claiming from April 1, 2021 through March 31, 2022 and the anticipated expenditures for activities the state intends to implement. CMS will approve state submissions that meet the terms of the guidance within 30 days. Until all of the enhanced funds are expended, states must submit quarterly HCBS spending plans and narratives that estimate the amount of enhanced funds that the state has claimed or anticipates claiming and anticipated and/or actual expenditures and provide progress reports on state activities. The guidance indicates that CMS will publicly post summary information from the state reports.

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

Key Findings

• The latest KFF COVID-19 Vaccine Monitor shows continued steady progress in vaccine uptake, with 62% of U.S. adults saying they’ve gotten at least one dose of a vaccine (up from 56% in April) and the share saying they will “wait and see” down slightly from 15% to 12%. This leaves few remaining eager to get vaccinated, while the shares saying they will get vaccinated “only if required” (7%) or will “definitely not” get a vaccine (13%) essentially unchanged over the last several months. Yet findings also suggest the overall adult vaccination rates could reach 70% over the next several months, with 4% saying they want the vaccine as soon as possible and about a third of the “wait and see group” (or 4% of all adults) saying they have already scheduled an appointment or plan to get the vaccine in the next 3 months.
• One potential avenue for further increasing vaccine uptake is full FDA approval of one of the vaccines currently authorized for emergency use, with about one-third (32%) of unvaccinated adults saying such approval would make them more likely to get vaccinated. In addition, one in five (21%) employed adults who have not gotten a vaccine say they would be more inclined to do so if their employer gave them paid time off to get vaccinated and recover from side effects. Certain financial incentives may also motivate small shares (between 10-15%) of the unvaccinated to get a vaccine. Such incentives, including free transportation from ride share companies, lead larger shares of Hispanic and Black adults as well as those with lower incomes to say they would get vaccinated, suggesting incentives could play a role in further decreasing racial, ethnic, and socioeconomic disparities in vaccination rates.
• Over four in ten adults (43%) say that CDC guidance on the types of activities that vaccinated and unvaccinated people can safely engage in is confusing and hard to follow, a share is similar among vaccinated and unvaccinated adults but rises to 56% among Republicans. The vast majority of those who have not been vaccinated say the new CDC guidelines stating that fully vaccinated people do not need to wear masks or practice social distancing in most situations does not make a difference in their own decision about whether to get vaccinated.
• Among parents of adolescents ages 12-17, four in ten (41%) say their child has already received at least one dose of the COVID-19 vaccine or they will get them vaccinated right away. Parents of younger children under age 12 are more cautious, with about a quarter saying they will get their young child vaccinated as soon as a vaccine is authorized for their age group and one-third saying they will take a “wait and see” approach.

Trends In COVID-19 Vaccination Intentions

While the share of U.S. adults who report receiving at least one dose of a COVID-19 vaccine has continued to climb from 56% in April to 62% in May, the share who say they intend to get the vaccine as soon as possible fell to just 4%, leaving a very small group that is ready to get vaccinated right away. At the same time, the share who say they want to “wait and see” before getting vaccinated inched downward from 15% to 12% over the past month, while the shares saying they will get a vaccine “only if required” for work or other activities, or will “definitely not” get vaccinated remain essentially unchanged since January.

Within most demographic subgroups of the population, there was an uptick between March and April in the share saying they have received a vaccine and a decrease in the share who say they have not gotten the vaccine but want it right away. The increase in self-reported vaccination rates between April and May was notable among Hispanic adults (from 47% to 57%) and those without college degrees (from 48% to 55%), two groups for whom vaccine uptake has lagged behind others. 

This leaves a picture that is very similar to April, with at least half of adults in almost every demographic group saying they’ve gotten at least one dose of a vaccine, including large majorities of older adults, those with serious health conditions, college graduates, and Democrats. Younger adults and Black adults remain disproportionately likely to say they will wait and see before getting a vaccine, while Republicans, rural residents, and White Evangelical Christians are disproportionately likely to say they will definitely not get vaccinated. Notably, after increasing somewhat last month, vaccine enthusiasm seems to have stalled among Republicans, with about half (49%) saying they’ve gotten at least one dose of the vaccine (statistically similar to the 52% who said so last month) and 27% saying they will definitely not get vaccinated.

How Long Will the “Wait and See” Keep Waiting?

While few who are eager remain unvaccinated, the Monitor does provide some indication that vaccination rates could continue to increase over the next few months. In addition to the remaining 4% of all adults who say they have not been vaccinated but plan to do so as soon as they can, about a third of those in the “wait and see” group (4% of all adults) say they either already have a vaccine appointment scheduled or that they will wait 3 months or less before getting vaccinated, suggesting the possibility that the adult vaccination rate could surpass 70% this summer. Still, over four in ten of those in the “wait and see” group say they intend to wait more than 6 months to get a vaccine, including one third who plan to wait more than a year.

What Else Might Encourage Vaccine Uptake?

Among various incentives tested in this month’s Monitor, the one that appears to have the most resonance, particularly for those in the “wait and see” group, is full FDA approval of one or more of the COVID-19 vaccines. About a third (32%) of those who have not been vaccinated, including 44% of those who say they want to “wait and see,” say they would be more likely to get vaccinated if one of the vaccines currently authorized for emergency use received full approval from the FDA. One in five (21%) of those who are employed and unvaccinated say they’d be more likely to get the vaccine if their employer gave them paid time off to get vaccinated and recover from any side effects.

Among various financial incentives, small shares of those who haven’t gotten a vaccine say they’d be more likely to do so if they were offered $100 from their state government (15%), free transportation from a ride sharing company (13%), free tickets to a sporting event or concert (11%), or a $20 coupon for items like food or drinks (10%).

The shares who say they’d be more likely to get vaccinated if offered many of these financial incentives are larger among some key populations among whom vaccination rates have lagged, including Black and Hispanic adults and those with lower household incomes. Notably, larger shares of Both Black and Hispanic adults compared to White adults who have not been vaccinated say they’d be more likely to get a vaccine if they were offered free transportation from a ride share company like Uber or Lyft, reflecting disproportionate concern about having difficulty traveling to a vaccination site among these populations identified in previous Monitor reports. These findings suggest that financial incentives and travel assistance could help further close gaps in vaccination rates between White communities and people of color, in addition to helping some adults with lower socioeconomic status get vaccinated.

There is also the possibility for incentives and requirements to get vaccinated to backfire with certain individuals. In fact, among those who have not been vaccinated and are not ready to get the vaccine as soon as possible, about four in ten (41%) say they have felt “unfairly pressured” to get the COVID-19 vaccine, including half of those who say they will “definitely not” get vaccinated (51%) and similar shares of women (48%) and college graduates (52%).

When those who report feeling unfair pressure are asked who they think has been applying that pressure, the most common responses include the government (36%), the media (19%), society in general (14%), and their friends, family, or coworkers (12%). 

Reactions to New CDC Guidance on Safe Activities for Fully Vaccinated Adults

On May 13, 2021, the Centers for Disease Control and Prevention (CDC) issued updated public health guidelines for activities that fully vaccinated people can safely engage in. Among other things, the new guidance states that fully vaccinated people no longer need to wear a mask or physically distance in any setting, except where required by other laws, regulations, or business restrictions. Asked how they feel about the CDC guidelines, just over half the public (54%) says they are “clear and easy to understand” and just over four in ten (43%) say they are “confusing and hard to follow”. Notably, similar shares of both vaccinated and unvaccinated adults say they find the guidance confusing, though there is a partisan divide with a majority of Republicans (56%) saying the guidance is confusing and majorities of Democrats (59%) and independents (60%) saying it is clear. This may reflect partisan differences in trust of the CDC as identified in previous Vaccine Monitor reports.

When those who have not been vaccinated for COVID-19 are asked how the new CDC guidance saying fully vaccinated people do not need to wear masks or social distance in most places might affect their own vaccination plans, the vast majority (85%) say it makes no difference. One in ten say this updated guidance makes them more likely to get vaccinated, but a small share (4%) say it makes them less likely to get a vaccine.

Parents’ Intentions for Vaccinating Children

With the recent FDA authorization for the use of the Pfizer COVID-19 vaccine in children ages 12 and older, the latest Monitor finds about four in ten (41%) parents of children ages 12-17 say their child has already received at least one dose of the vaccine (24%) or that they will get them vaccinated right away (18%). About one in five parents of adolescents say they will “wait a while to see how it is working” before getting their child vaccinated (21%), while 14% say they will get their child vaccinated only if their school requires it and another one in five say they will “definitely not” get their 12-17 year-old vaccinated.

Parents of younger children, for whom a COVID-19 vaccine is not yet authorized, are more cautious in their approach to the vaccine. One-quarter (26%) say they will get their child under age 12 vaccinated as soon as a vaccine is authorized for their age group, while one-third intend to wait a while to see how the vaccine is working. An additional 14% say they will vaccinate their young child only if school requires it and one-quarter (26%) say they will definitely not get them vaccinated.

Parents’ own vaccination status is correlated with their intentions to vaccinate their children for COVID-19. Among parents of children under age 12 who have received a vaccine themselves, nearly half (46%) say they will get their younger child a vaccine as soon as one is authorized for their age group compared to just 8% of parents who have not received a vaccine. By contrast, 42% of unvaccinated parents say they will “definitely not” get their child under age 12 vaccinated compared to just 8% of parents who have received the vaccine themselves.

When parents are asked the biggest question they have when it comes to their child receiving a COVID-19 vaccine, the questions echo many of the concerns we have heard from adults about getting the vaccine themselves. One in five parents mention questions about potential side effects or negative reactions to the vaccine, and another 10% have questions about long-term side effects specifically. Six percent of parents say they want to know more about the research that was done on children and 5% have questions about the safety of the vaccine for children. Smaller shares mention questions about vaccine effectiveness, availability, and whether it’s necessary for children to get vaccinated. About one in five parents (19%) say they do not have any questions when it comes to their child receiving a vaccine.

These questions and concerns don’t necessarily reflect a resistance among parents to vaccines more broadly. Just 11% of parents say they have ever delayed or skipped other vaccines for their children.

This KFF COVID-19 Vaccine Monitor was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted May 18-May 25, 2021, among a nationally representative random digit dial telephone sample of 1,526 adults ages 18 and older (including interviews from 327 Hispanic adults and 307 non-Hispanic Black adults), living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Phone numbers used for this study were randomly generated from cell phone and landline sampling frames, with an overlapping frame design, and disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity subgroups within each frame. Specifically, the cell phone frame was stratified as: (1) High Hispanic: Cell phone numbers associated with rate centers from counties where at least 35% of the population is Hispanic; (2) High Black: Cell phone numbers associated with remaining rate centers from counties where at least 35% of the population is non-Hispanic Black; (3) Else: numbers from all remaining rate centers. The landline frame was stratified as: (1) High Black: landline exchanges associated with Census block groups where at least 35% of the population is Black; (2) Else: all remaining landline exchanges. The sample also included 162 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll at least nine months ago. Another 134 interviews were completed with respondents who had previously completed an interview on the SSRS Omnibus poll (and other RDD polls) and identified as Hispanic (n = 46; including 19 in Spanish) or non-Hispanic Black (n=88). Computer-assisted telephone interviews conducted by landline (248) and cell phone (1,278, including 963 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2019 U.S. American Community Survey (ACS), on sex, age, education, race, Hispanic origin, and region, within race-groups, along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January- June 2020 National Health Interview Survey The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample, and design modifications, namely, the oversampling of potentially undocumented respondents and of prepaid cell phone numbers, as well as the likelihood of non-response for the re-contacted sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

 

• The U.S. is the largest donor to global health in the world, and funding for global health has grown over time. To provide context for the release of the first, full budget request from the Biden administration, this brief provides an overview of trends in U.S. global health funding. It examines both regular as well as supplemental, or emergency, appropriations over time, changes in funding for major program areas, and trends in the distribution between bilateral and multilateral support.
• U.S. funding for global health, through regular appropriations, has grown significantly over the past two decades, rising from $1.7 billion in FY 2001 to $11.4 billion in FY 2021, with the steepest increase occurring in the earlier decade. Most of the increase ($8.3 billion or 85%) was provided between FY 2001–FY 2011, a decade which marked the creation of PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the President’s Malaria Initiative.
• Since FY 2011, funding increases have been more modest. Between FY 2011 and 2021, funding rose by $1.4 billion, most of which has come in recent years. There were also fluctuations over the period, including some declines.
• Funding for most global health program areas has increased since FY 2011, particularly the Global Fund and global health security; funding was flat for PEPFAR and declined for family planning and reproductive health. All other program areas – tuberculosis, malaria, maternal and child health, nutrition, vulnerable children, and neglected tropical diseases – increased over the period.
• Most global health funding has been provided bilaterally (ranging from 79-85% between FY 2011 and 2021), but the amount and share of funding for multilateral organizations has increased at a faster rate. Bilateral funding increased by 8% over the period while multilateral funding increased by 48%. Funding for multilateral organizations now makes up a fifth (20%) of the global health budget, up from 15% in FY 2011.
• Emergency funding, provided to respond to specific disease threats, has become a more prominent part of the global health budget in recent years. Since FY 2011, the U.S. has provided $11.8 billion in emergency funding for global health (9% of overall global health funding over the period). Most of this funding (90%) has been provided for COVID-19. Emergency funding has also been provided to respond to Ebola and Zika outbreaks.

Introduction

On April 9, 2021, the Biden administration released an initial, discretionary FY 2022 budget request to Congress, kicking off the annual budget process (see Appendix). While a full budget request is expected at the end of May, the initial proposal includes $10 billion for global health activities (see Box 1), with a heavy focus on and significant increase for ($800 million above FY 2021 levels) global health security. Although Congress ultimately determines funding levels each year, the president’s budget request serves as an important indication of the administration’s priorities. The President’s first budget request is especially significant as it will provide an important signal for the administration’s broader approach to and priorities for U.S. global health engagement. Indeed, COVID-19 has elevated global health security in particular to the top of U.S. domestic and international agendas, and the President has already taken steps to bolster U.S. global health engagement, including rejoining the World Health Organization (WHO) and joining COVAX, the global mechanism to secure and deliver COVID-19 vaccines. To provide context for the release of the administration’s first, full budget request for FY 2022, this brief provides an overview of historical trends in U.S. global health funding, including changes in program-specific funding over time, the distribution between bilateral and multilateral support, and in the increasing use of emergency supplemental funding in response to outbreaks, which has become a more prominent part of the U.S. global health budget.

Trends in Overall Funding for Global Health Through Regular Appropriations

Global health represents the largest share of U.S. international development aid,¹  and funding for global health through regular appropriations has grown significantly since FY 2001. Between FY 2001, when funding was $1.7 billion, and FY 2021, funding for global health increased by almost $10 billion, most of which ($8.3 billion or 85%) was provided between FY 2001–FY 2011, marking the creation of PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the President’s Malaria Initiative. Funding increases slowed in the years after the global financial crisis that began in 2008, and even declined slightly in the early part of the next decade. While it somewhat recovered, increases over the past decade have been more modest, rising by $1.4 billion between FY 2011 and FY 2021, driven primarily by increases to the Global Fund and global health security.²  In FY 2021 U.S. funding for global health through regular appropriations totaled $11.4 billion, its highest level to date.³  Additional funding has also been provided through emergency, supplemental funding (see below).

Program Area Trends

While funding for most global health program areas increased over the last decade, funding for PEPFAR (bilateral HIV) remained flat and funding for family planning and reproductive health (FP/RH) declined; overall funding, as well as funding for all program areas, fluctuated over the period. The biggest increases were for the Global Fund (which represented the largest dollar amount increase) and global health security (which represented the largest percentage increase) (see Figure 2).

Key program area trends over the past decade include the following:

• PEPFAR (Bilateral HIV). PEPFAR funding has ranged between $4.7 billion and $5.5 billion since FY 2011, though current levels are about the same as funding a decade ago (see Figure 3). There was a significant dip in funding after FY 2012 (of more than $400 million), and funding did not rebound until FY 2019, where it has remained since. While funding for bilateral HIV programs has historically accounted for the largest share of the U.S. global health budget, its share has declined over time, dropping from 54% in FY 2011 to 48% in FY 2021 (see Figure 4). Bilateral HIV funding is provided through the GHP account at USAID and State, the ESF account at USAID, and through CDC, NIH, and DoD. Additional funding for PEPFAR was recently provided through emergency COVID-19 funding (see below).
• The Global Fund. The U.S. has been the largest donor to the Global Fund since its inception. U.S. contributions to the Global Fund in FY 2021 ($1,560 million) were $514 million (49%) above the FY 2011 level ($1,046 million), the largest increase of any global health program, although funding fluctuated over the period (see Figure 2 and 3). The Global Fund has represented the second largest share of the U.S. global health budget, and that share has increased somewhat, from 10% to 14% over the period (see Figure 4). U.S. funding for the Global Fund is provided through the GHP account at State. In the past, some funding has also been channeled through NIH as well. Additional funding for the Global Fund was recently provided through emergency COVID-19 funding (see below).
• Maternal and Child Health (MCH). MCH funding, which includes funding for polio, Gavi, the Vaccine Alliance (Gavi), and the United Nations Children’s Fund (UNICEF), in FY 2021 was $261 million (27%) above FY 2011 level ($974 million), although there was fluctuation over the period (see Figures 2 and 3). Increases in funding are largely due to increases in funding for polio efforts and for Gavi. When polio and Gavi amounts are removed, other MCH funding in FY 2021 ($703 million) was $47 million (-6%) below the FY 2011 level ($751 million). MCH funding has accounted for the third largest share of the U.S. global health budget over the decade and is provided through the GHP, ESF, AEECA, and DA accounts at USAID, as well as through the State Department and CDC (see Figure 4). Additional funding for Gavi was recently provided through emergency COVID-19 funding (see below).
• Malaria. Global malaria funding, most of which is provided through the President’s Malaria Initiative, in FY 2021 was $179 million (22%) above the FY 2011 level ($800 million), with the largest increase occurring between FY 2016 and FY 2017 (see Figures 2 and 3) Funding for global malaria efforts has represented the fourth largest share of the U.S. global health budget and is provided through the GHP account at USAID, as well as through CDC, NIH, and DoD (see Figure 4).
• Family Planning and Reproductive Health (FP/RH). Funding for international FP/RH in FY 2021 ($608 million) was $25 million (-4%) below the FY 2011 level ($633 million), representing the only global health program area that decreased over the period (see Figure 2). FP/RH funding, which has represented the fifth largest share of the global health budget, fluctuated slightly during the earlier part of the decade and has remained flat at $608 million in recent years (see Figures 3 and 4). Funding is provided through the GHP, ESF, and AEECA accounts at USAID, as well as through contributions to UNFPA provided through the State Department. From FY 2017- FY 2020, the Trump administration invoked the Kemp-Kasten amendment, withholding funding for UNFPA and reallocating it to USAID’s family planning, maternal, and reproductive health activities (see the KFF Kemp-Kasten explainer).
• Global Health Security. Global health security funding in FY 2021 ($670 million) was $273 million (69%) above the FY 2011 level ($397 million), representing the largest percentage increase compared to all other program areas (see Figure 2). Despite these overall increases, there was some fluctuation over the decade (see Figure 3). Global health security has represented the sixth largest share of the U.S. global health budget, and that share has increased somewhat (from 4% in FY 2011 to 6% in FY 2021). Funding is provided through the GHP and ESF accounts at USAID, as well as through CDC and DoD. Much of the growth in global health security funding occurred in recent years in response to specific disease outbreaks, leading to more attention to pandemic preparedness and global health security (see later section on emergency supplemental funding for more details on funding for Ebola, Zika, and COVID-19).
• Tuberculosis (TB). Global TB funding in FY 2021 ($332 million) was $94 million (39%) above the FY 2011 level ($238 million) (see Figure 2). Most of this growth has occurred in recent years (see Figure 3). Funding is provided through the GHP and ESF accounts at USAID, as well as through CDC.
• Nutrition. Global nutrition funding in FY 2021 ($150 million) was $57 million (62%) above the FY 2011 level ($93 million), with much of the increase occurring in the earlier part of the decade and flattening in recent years (see Figures 2 and 3). Funding is provided through the GHP, ESF, and DA accounts at USAID.
• Neglected Tropical Diseases (NTDs). Global NTD funding in FY 2021 ($103 million) was $26 million (34%) above the FY 2011 level ($77 million), with much of the increase occurring earlier in the decade and flattening in recent years (see Figures 2 and 3). Funding is provided through the GHP account at USAID.
• Vulnerable Children. Funding for the vulnerable children program, the smallest global health program, in FY 2021 ($25 million) was $10 million (67%) above the FY 2011 level ($15 million), with funding growing steadily throughout the period (see Figures 2 and 3). Funding is provided through the GHP account at USAID.
• Other. Funding for global health is also provided to the World Health Organization (WHO) and Pan American Health Organization (PAHO) (see more details for these organizations in the multilateral funding section below), as well as the Fogarty International Center (FIC) at NIH and an “Emergency Reserve Fund” at USAID, which was created in FY 2017.⁴  Together, this funding increased slightly when comparing FY 2021 to FY 2011 levels (see Figures 2 and 3).

Trends in Bilateral vs Multilateral Funding

U.S. global health funding is provided through two types of channels: bilateral (i.e. country-to-country) and multilateral (i.e. multi-country, pooled support directed through an international organization; see Box 2). While the vast majority of U.S. funding for global health is provided bilaterally (ranging from 79-85% of the global health budget from FY 2011 to FY 2021), both the amount and share of funding for multilateral organizations has increased at a faster rate. Bilateral funding increased by 8% over the period while multilateral funding increased by 48%. The multilateral share, which increased over the decade (and experienced fluctuations throughout the period), now represents about a fifth (20%) of U.S. global health funding in FY 2021, up from 15% in FY 2011 (see Figure 5 and 6).⁵ 

Funding for most multilateral organizations increased in FY 2021 compared to FY 2011 levels, with the exception of the TB Global Drug Facility, which remained flat, and UNFPA, which decreased overall and did not receive funding in some years due to the Kemp Kasten amendment (see Figure 7). ⁶   While Gavi increased by the greatest percentage amount (223%) compared to other multilateral organizations, the Global Fund increased by the largest dollar amount ($514 million compared to Gavi’s $200 million increase). The Global Fund has represented 67-75% of multilateral funding for global health each year over the past decade. Funding for the Global Fund, while rising overall, fluctuated over the past decade, in contrast to all other multilateral organizations, which either increased or remained essentially flat over the period, except for UNFPA (see Figure 8).

Trends in U.S. Emergency Supplemental Funding

In addition to global health funding provided through regular appropriations, emergency funding, appropriated in response to outbreaks, has become a more prominent part of the budget. Since FY 2011, the U.S. has provided $11.8 billion in emergency supplemental funding (representing 9% of overall global health funding over the period) to address outbreaks, almost all of which (90%) has been provided in response to COVID-19 (see Figure 9). Global health funding through emergency appropriations over the past decade includes:

• $909 million in FY 2015 to address Ebola.⁷ 
• $145.5 million in FY 2016 to address Zika.⁸ 
• $10.6 billion to address COVID-19 ($1.2 billion in FY 2020 and $9.4 billion in FY 2021).⁹  Of this, $4 billion was provided to COVAX, $250 million to PEPFAR, and $3.5 billion to the Global Fund.

Looking Ahead

The U.S. government is the largest donor to global health in the world.¹⁰  As this analysis demonstrates, U.S. funding for global health has grown significantly over time, marking the start of major new programs. However, the vast majority of that growth occurred from FY 2001 to 2010, with the creation of PEPFAR. In the last decade, funding for most program areas within the global health budget has increased, but only quite modestly. In addition, the U.S. has provided a significant amount of emergency supplemental funding on top of regular appropriations for global health to respond to disease outbreaks in recent years. While the Biden administration has already taken steps to bolster U.S. global health engagement, largely in response to the COVID-19 pandemic, the forthcoming release of his first, full budget request for FY 2022 will provide an important window into the administration’s further priorities for global health.

U.S. Annual Budget Process¹¹ 

The U.S. annual budget process starts when the President submits a detailed budget request to Congress for the upcoming fiscal year, which begins on October 1 and ends on September 30. Signaling the administration’s priorities, the request, which is developed through an interactive process between federal agencies and the President’s Office of Management and Budget (OMB), includes recommendations to Congress on funding levels for federal programs. The request is usually submitted by the first Monday in February, but sometimes the submission is delayed, particularly when a new administration takes office, as is the case today. In addition, when a new administration takes office, sometimes the President submits an initial, abbreviated budget, as was done this year (this was also done at the beginning of both the Obama and Trump administrations), and a fuller more detailed budget later. Once the President submits the detailed budget request to Congress, the House and Senate develop a budget plan, or a “budget resolution,” through their budget committees. After both the House and Senate pass these budget resolutions, a process that generally takes place in March or April, the bills go to the floor, where a conference between the House and Senate resolves any differences within the budget resolution and an agreement between the two houses is made. The budget resolution serves as a blueprint for the actual appropriations process, where House and Senate Appropriations committees set spending totals for federal agencies and programs. Once each appropriations committee sets these amounts and allocations, the bills are considered by the House and Senate, where a conference agreement, which resolves any differences between the two bills, is made. Once a conference bill is passed by both the House and Senate, it goes to the President and is signed into law.

1. KFF analysis of OECD DAC CRS database, May 2021. ↩︎
2. In FY 2013, sequestration occurred, resulting in cross the board cuts in funding to all global health program areas. ↩︎
3. Represents U.S. regular appropriations only. ↩︎
4. The Emergency Reserve Fund at USAID was created in the FY 2017 Omnibus bill to respond to contagious infectious disease outbreaks and would be made available if there is an “emerging health threat that poses severe threats to human health.” The only year the Emergency Reserve Fund received funding through regular appropriations was in FY 2017. ↩︎
5. U.S. multilateral funding includes support to the Pan-American Health Organization (PAHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children’s Fund (UNICEF), United Nations Family Planning Agency (UNFPA), World Health Organization (WHO), Gavi, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the TB Global Drug Facility. ↩︎
6. While Congress provided funding for UNFPA each year between FY 2011 and FY 2021, President Trump invoked the Kemp-Kasten amendment to withhold funding from the organization (see KFF explainer on UNFPA funding & Kemp-Kasten amendment). President Biden has directed the U.S. Secretary of State to take the necessary steps to resume funding to UNFPA. ↩︎
7. KFF. The U.S. Response to Ebola: Status of the FY2015 Emergency Ebola Appropriation; December 2015. ↩︎
8. KFF. The Status of Funding for Zika: The President’s Request, Congressional Proposals, & Final Funding; October 2016. ↩︎
9. KFF. Global Funding Across U.S. COVID-19 Supplemental Funding Bills; March 2021. ↩︎
10. KFF. Donor Funding For Health in Low-& Middle-Income Countries, 2002-2013. November 2015. https://modern.kff.org/global-health-policy/report/donor-funding-for-health-in-low-middle-income-countries-2002-2013/. ↩︎
11. U.S. government, “Budget of the U.S. Government” webpage, October 2019. Accessed: https://www.usa.gov/budget. Congressional Research Service, “Introduction to the Federal Budget Process”, February 26, 2020. Center on Budget and Policy Priorities, “Policy Basics: Introduction to the Federal Budget Process” webpage, April 2020. Accessed: https://www.cbpp.org/research/introduction-to-the-federal-budget-process ↩︎

The American Rescue Plan Act (ARPA) was passed by Congress and signed into law by President Biden in March 2021. The ARPA includes provisions that increase subsidies for Marketplace shoppers who were already eligible for financial assistance and removes the upper income cap on subsidy eligibility, eliminating what was known as the “subsidy cliff.” As a result, KFF estimated that roughly 3.7 million more Americans, more than a third of whom are uninsured, are newly eligible for financial assistance to buy their own coverage on the exchanges, and millions more are eligible for increased financial assistance.

As of April 30, nearly 1 million people had enrolled in a HealthCare.gov plan during the ongoing special enrollment period, which lasts through August 15. The Centers for Medicare and Medicaid Services (CMS) announced an outreach campaign to inform people about Marketplace enrollment opportunities and the enhanced financial assistance. For 2021 and 2022, CMS released over $80 million in grants to Navigators and related organizations that help consumers enroll in coverage and provide outreach and educational services. The Trump administration had made substantial cuts to ACA marketing activities and Navigator programs, which received just $10 million in grants in both 2018 and 2019.

In this analysis, we examine key demographic characteristics of the 10.9 million uninsured people who are eligible for Marketplace subsidies, including 6 million uninsured individuals eligible for tax credits that cover the full cost of a Marketplace plan. We exclude people who are eligible for Medicaid, Medicare, or affordable employer coverage, as well as those who are undocumented immigrants. We also exclude people who fall into the Medicaid coverage gap, since Marketplace coverage is generally unaffordable to people with incomes below poverty.

We find that relatively large shares of uninsured people eligible for significant assistance to buy Marketplace coverage are young adults without college educations, Hispanic, non-native English speakers, and working in the fields of entertainment, recreation, and construction. Most people eligible for free Marketplace coverage are concentrated in a handful of states (Texas, Florida, North Carolina, and Georgia). These findings can inform marketing, outreach, and enrollment assistance activities as the 2021 special enrollment period continues and consumers begin shopping for 2022 coverage later this year.

Findings

We estimate there are approximately 12.1 million¹  uninsured potential Marketplace shoppers, of whom the vast majority (10.9 million) are eligible for subsidies under the ACA and ARPA to help lower the cost of coverage.

Nationally, certain groups are overrepresented among the uninsured who are eligible for Marketplace subsidies following the enactment of the ARPA. We find that 30% of uninsured people eligible for Marketplace subsidies are Hispanic (compared to 20% of non-elderly people in the U.S.), 59% have a high school diploma or less (compared to 36% of non-elderly adults in the U.S.), and 42% are young adults ages 19 to 34 (compared to 25% of non-elderly people in the U.S.). In total:

• 10.9 million uninsured people could purchase Marketplace coverage for a reduced premium. Although subsidies for this group may not cover the full premium, they can significantly lower the premium and/or out-of-pocket liability. Even so, some people in this group may still find Marketplace coverage unaffordable or unattractive due to high deductibles.
• At least 6.0 million uninsured people could get a free Marketplace plan (with a $0 premium payment, after accounting for subsidies). As explained in our earlier brief and in some detail below, people in this group would clearly benefit from getting Marketplace coverage rather than continuing to go without coverage.
• Of uninsured people who are eligible for $0 premium plans, 1.3 million have incomes below 150% of poverty, which makes them eligible for a free benchmark silver plan and substantial cost-sharing reductions (CSRs) that would make their plan more similar to platinum level coverage (which an average deductible of $177 in 2021). Some people with incomes just above 150% of poverty may also qualify for zero-premium silver plans depending on the gap in price between the benchmark (second-lowest cost) silver plan and the lowest-cost silver plan in their area.
• In addition, under the ARPA, any person who qualifies to purchase a Marketplace plan and receives unemployment compensation in 2021 is similarly eligible for a benchmark silver plan with a $0 premium and cost-sharing assistance. Therefore, our estimate of the number of uninsured people eligible for zero-premium plans is likely an undercount.

Subsidy ELigible uninsured: key characteristics

We estimate that 10.9 million non-elderly uninsured people in the U.S. are eligible for some level of subsidy to help purchase a Marketplace plan. Relative to the general non-elderly population in the U.S., uninsured people eligible for Marketplace subsidies are more likely to be:

• High school educated: 59% of subsidy eligible adults have a high school education or less, compared to 36% of non-elderly adults in the U.S.
• Young Adults: 42% of subsidy eligible uninsured people are ages 19-34, compared to 25% of the non-elderly U.S. population.
• Hispanic: 30% of subsidy eligible uninsured people are Hispanic, compared to 20% of the non-elderly U.S. population.
• Living in rural areas: 16% of subsidy eligible uninsured people live in non-metro areas, compared to 13% of the non-elderly U.S. population.
• Lacking internet access: 11% of subsidy eligible uninsured people do not have internet access at home, compared to 6% of the non-elderly U.S. population.

uninsured eligible for Zero premium plans: key characteristics

We estimate that at least 6.0 million uninsured people in the U.S. could get a bronze or silver plan on the ACA Marketplace with a $0 premium contribution, after accounting for their subsidy. Compared to the total subsidy-eligible uninsured population and the general U.S. population, uninsured people eligible for free Marketplace plans are more likely to be:

• High school educated: 62% of free bronze eligible uninsured adults and 65% of the free silver eligible uninsured people have a high school education or less, compared to 59% of all subsidy-eligible uninsured people and 36% of all non-elderly adults in the U.S.
• Hispanic: 32% of free bronze eligible uninsured people and 41% of the free silver eligible uninsured people are Hispanic, compared to 30% of all subsidy eligible uninsured people and 20% of the total non-elderly population.
• Lacking internet access: 13% of the free bronze eligible uninsured people and 15% of free silver eligible uninsured people do not have internet access at home, compared to 11% of all subsidy eligible uninsured people and 6% of the total non-elderly population.
• Non-English speaker at home: 35% of free bronze eligible uninsured people and 46% of free silver eligible uninsured people speak a language other than English at home, compared to 23% of the U.S. non-elderly population.

In addition to the 1.3 million uninsured people who qualify for zero-premium benchmark silver plans because their income is less than 150% of poverty, there are likely many more uninsured people who qualify for free silver plans because the ARPA ensures that any enrollee receiving unemployment insurance at some point in 2021 is eligible for zero-premium platinum-like coverage. As noted above, there are also some uninsured people with incomes just above 150% of poverty who would have to pay a small premium for a benchmark silver plan, but may receive enough in subsidies to cover the full cost of the lowest-cost silver plan in their area. Further, there are many counties in the U.S. where the lowest-cost gold plan is cheaper than the lowest-cost silver plan. Lower-income Marketplace shoppers in these areas could potentially purchase a free gold plan with lower cost-sharing and more financial protection than plans in lower metal levels.

As we have explained in earlier analyses, many people who are eligible for a free bronze plan are also eligible for a low-cost silver plan with a substantially lower deductible due to CSRs. The average annual deductible for people with incomes between 150-200% of poverty who choose to enroll in a silver plan with a CSR is $800. Many people in this group, therefore, could be better off buying a silver plan with a small premium than a zero-premium bronze plan.

Even so, all of the uninsured eligible for a free bronze or a free silver plan would be better off taking advantage of that $0 premium coverage instead of remaining uninsured. People in this group may need help understanding the tradeoff between silver and bronze coverage (i.e. affordability of the premium and deductible), as well as help understanding the benefits that even a high-deductible bronze plan offers over being uninsured (i.e. free preventive care, limited out-of-pocket liability, lower negotiated payment rates to providers, and often at least some covered benefits before having to meet the deductible).

Almost half of the uninsured who could get a free bronze plan live in Texas, Florida, North Carolina, or (Figure 1). A detailed table in the appendix provides demographic characteristics of people eligible for free Marketplace coverage in each state.

Discussion

The findings of this analysis can inform government agencies, insurers, or Navigators tasked with outreach and marketing responsibilities, helping them to target specific groups that are more likely to be uninsured but eligible for significant financial assistance. The Department of Health and Human Services has announced concerted efforts to reach historically uninsured communities during the ongoing special enrollment period. Relatively large shares of uninsured people eligible for significant assistance to buy Marketplace coverage are young adults without college educations, Hispanic, non-native English speakers, and working in the fields of entertainment, recreation, and construction. Most people eligible for free bronze or silver coverage are concentrated in a handful of states (including Texas, Florida, Georgia, and North Carolina).

In addition to the findings highlighted above, the appendix of this brief provides detailed demographics about the uninsured population eligible for fully-subsidized coverage in each state.

2021 Premiums come from KFF analysis of premium data from Healthcare.gov and state rating filings. Data on population, income, and eligibility for subsidies come from KFF analysis of the Census Bureau’s 2019 American Community Survey (ACS). The ACS includes a 1% sample of the US population and allows for precise state-level estimates. The ACS asks respondents about their health insurance coverage at the time of the survey. Respondents may report having more than one type of coverage; however, individuals are sorted into only one category of insurance coverage. The 2019 ACS collected income and coverage data from respondents before the pandemic, but there are various reasons that the data are still a reasonable basis for current uninsured eligibility analyses. First, the national uninsured rate has stabilized in recent years and expectations are that it has remained relatively flat thus far during the pandemic. Second, at least prior to enhanced subsidies outlined in the ARPA, the number of uninsured people eligible and ineligible for subsidies have also stayed generally consistent. Under the previous ACA subsidy structure, KFF estimated the number of uninsured people eligible for free bronze plans had fluctuated between 4.0 and 4.7 million the past three years.

This analysis does not include individuals who are over the age of 65, who are eligible for Medicaid in 2021, who have incomes below poverty, or are undocumented immigrants. We exclude individuals who are uninsured but have an affordable offer of employer-based coverage. Under the current ACA structure, workers and their family members are ineligible for tax credits if any worker in the household is offered “affordable” health insurance through their employer. Employer coverage is considered affordable if the worker’s premium contribution for self-only amounts to less than 9.83% of household income.

Unsubsidized premiums used in this analysis are the full price of plans, rather than specifically the portion that covers essential health benefits (EHB). Since premium tax credits can only be used to cover the EHB portion of premiums, some of the individuals denoted as having access to a “free” bronze plan might actually have to pay a very small premium for non-essential health benefits if they enrolled in a bronze plan with added benefits. The ACA does not permit federal subsidies to pay for abortion coverage and requires plans to collect no less than $1.00 per month for this coverage. In CA, IL, NY, ME, OR, and WA, state law requires that that all state regulated plans include abortion coverage. Policyholders who live in these states must pay the abortion surcharge even though they may qualify for subsidies that provide the full cost of premiums if they select a bronze plan. Providence Health Plans in OR and WA have a religious exemption allowing them to exclude abortion coverage.

1. This estimate includes people who are subsidy eligible and people who are ineligible for subsidies because their premiums are too low relative to their incomes. It excludes people who are eligible for Medicare, Medicaid, or affordable employer coverage, as well as those who are undocumented immigrants. People who fall into the Medicaid coverage gap are also excluded because Marketplace coverage is generally unaffordable for people with incomes below poverty. If we include people with affordable employer offers of coverage, there are approximately 15 million uninsured people who are eligible to purchase ACA Marketplace plans. ↩︎