Digging Back Into The Sun Belt Voices Project

In early fall 2020, KFF in collaboration with the Cook Political Report conducted the Sun Belt Voices Project which included interviews with a random sample of 3,479 registered voters in three Sun Belt states (1,298 in Arizona, 1,009 in Florida, and 1,172 in North Carolina). Relying on an innovative probability-based approach of contacting registered voters sampled from voter registration files and allowing respondents to participate online or over the telephone, the project had two main goals, 1) to provide insights into the attitudes and experiences of voters in three key states for the 2020 presidential election; and 2) examine the issues that resonate with and motivate voters in state s in which shifting population characteristics are resulting in increasing Democratic vote shares in more traditionally Republican region of the U.S..

The original report released on September 17, 2020 found most voters had made up their minds about who they were going to vote for with more than six weeks before the official Election Day and that President Trump was a motivating force for both voters who intended to vote for the former President as well as those who were planning on voting for now-President Biden.

Now, more than nine months after we conducted the survey and six months after the 2020 presidential election, we are looking back into the data we collected and matching it with actual voter records from Election Day to better understand the demographics of voters who cast ballots during this election. By matching the original sample file from L2, including those who participated in the survey as well as those who were contacted to participate but did not, with the updated voting records from the 2020 election, this new analysis examines whether voters’ planned intentions to vote match their actual turnout in the 2020 presidential election. In addition, it does a deep dive into better understanding the demographics and views of the new 2020 voters who did not vote in the 2016 election. These voters fall into two categories: low propensity voters (those who were eligible to vote in 2016 but chose not to) and newly eligible voters, for whom the 2020 election is the first general election for which they are at least 18 years old.

Finally, this analysis examines whether the sampling methodology used in this project can help researchers better understand how the polling field can adapt to reach voters missed by traditional polling methodologies, a problem that contributed to underestimates of President Trump’s vote margins across key states in pre-election polling.

Executive Summary

The 2020 presidential election was unlike any other election in U.S. history. It was held in the middle of a global pandemic as the nation grappled with issues around the coronavirus, police violence against black Americans, and an uncertain economy. In an effort to address concerns about voting in-person, many states expanded access to early voting and absentee (mail-in) ballots and after all of the votes were counted, it was the highest voter turnout in more than a decade.

One of the major narratives out of the 2020 election, especially in the absence of a decision on Election Night, was that pre-election polls incorrectly estimated the support for President Trump in key battleground states. While the Sun Belt Voices Project was conducted more than six weeks prior to the election and was not designed to estimate support for the presidential candidates, our goal in this analysis was to examine whether the polls we conducted in Arizona, Florida, and North Carolina misgauged voters’ opinions and experiences leading up to Election Day. By linking the data we collected from the survey with voter records, we can better understand which voters chose to cast ballots in the 2020 election and whether their views and experiences were different than those who chose not to vote.

Several theories have arisen to explain why both the national polling average and state polling averages in the weeks leading up to the presidential election underestimated President Trump’s vote share. The first is turnout. In a high turnout election, it is more difficult for pollsters to predict who is going to show up to vote as you can’t rely on past voting behavior. Our analysis finds one-third of 2020 general election voters in our sample are “new” voters, that is they did not vote in the 2016 presidential election. This includes one quarter (26%) of total voters who were low propensity voters – voters who had been eligible in 2016 (at least 22 years old in 2020) but did not vote in 2016, and an additional 6% who were newly eligible to vote.

Tied to turnout is the role of Hispanic voters in the 2020 election. Our analysis finds a disproportionate share of Hispanic voters are in the low propensity voter group as over one-third of Hispanic voters who were eligible in 2016, but chose not to vote, chose to vote in 2020 (an additional 12% of Hispanic voters were newly eligible for this historic election). This may be due to increased access to absentee (mail voting) in Florida and North Carolina. Overall, a slightly larger share of new 2020 voters said they voted absentee (through the mail) with seven in ten (72%) low propensity voters taking advantage of absentee voting, and an additional one in five voted early in person. Our analysis finds neither political party had an advantage among the low propensity voters, but the Democratic Party did have a slight advantage among the newly eligible voters.

In the 2016 election, there was some evidence that many late deciding voters went disproportionately for President Trump in key battleground states. Overwhelmingly, self-reported turnout and enthusiasm matched what voters ended up doing in the 2020 election. The vast majority (91%) of voters who voted in the 2020 election reported they were “absolutely certain to vote” back in September and many Sun Belt voters who decided not to vote in the 2020 election had previously reported they were less motivated to vote and were “undecided” about their vote choice. While some of these voters did choose to cast a ballot, our analysis finds they were not disproportionately Republican or viewed President Trump more favorably. In fact, most of them identified as political independents.

What is clear in our analysis and others’ is that polls are missing a certain segment of voters who disproportionately supported President Trump. There has not been any evidence of “shy Trump voters” (voters who support President Trump may not be honest about their support for him either to purposely mislead researchers or because of a social desirability desire) in analyses of both the 2016 election and the 2020 election, and our results are similar. Voters who participated in the 2020 KFF/Cook Political Report Sun Belt Voices are representative of the demographics of all voters who voted in the 2020 election (in terms of education, race and ethnicity, and political partisanship), and those who chose to complete the survey online were no more likely to state support for President Trump. Yet, we strongly believe there is more work to do in better understand how polling’s failure to include or appropriately weight for a certain group of voters produced error that could explain a large portion of the polling error during the 2020 election and could have implications in future polls, both pre-election polls and others.

Key Findings

• One-third (32%) of 2020 general election voters in Florida, North Carolina and Arizona are “new” voters, that is they did not vote in the 2016 presidential election. This includes one quarter (26%) of total voters who were low propensity voters—voters who had been eligible in 2016 (at least 22 years old in 2020) but did not vote in 2016, and an additional 6% who were newly eligible to vote.
• Half (47%) of the Hispanic voters in Arizona, Florida, or North Carolina who cast their ballots in the 2020 election did not vote in 2016. This includes one-third of Hispanic voters who were eligible in 2016, but chose not to vote, and an additional 12% who were newly eligible for this historic election. One in three White (28%) and Black (30%) voters and in the three states had not voted in 2016.
• Increased access to absentee or mail voting as well as early in-person voting was a key element in the 2020 election and may have both mitigated some concerns about exposure to coronavirus while voting and modestly expanded access to some groups that had not previously voted. Two-thirds of 2020 voters who participated in the Sun Belt Voices Project cast absentee ballots while the remaining shares either voted early in-person (22%) or voted in-person on Election Day (11%). A slightly larger share of new 2020 voters said they voted absentee (through the mail) with seven in ten (72%) low propensity voters taking advantage of absentee voting, and an additional one in five voted early in person.
• Unlike the 2016 election, no major news event drastically impacted voters’ motivations or intentions during the last weeks of the 2020 presidential campaign. Many Sun Belt voters who decided not to vote in the 2020 election had previously reported they were “undecided” about who they were planning to vote for in the presidential election, and two in ten (22%) of them reported being “less motivated” to vote in 2020 compared to 2016 (compared to 6% of voters who voted in 2020), as well as said their chances of voting in the 2020 election were 50-50 or less. On the flip side, 91% of voters who voted in the 2020 election reported they were “absolutely certain to vote” back in September.
• There were some late deciders in the KFF/Cook Political Report Sun Belt Voices pollingMore than three-fourths of voters who reported being “undecided” about who they would cast their ballot for in their responses to the Sun Belt Voices Projectconducted in early September ended up voting in the 2020 presidential election. While we do not know which candidate they chose to vote for, our analysis finds that half of these undecided voters identify as political independents (53%), 27% identify as Republicans or Republican-leaning independents and 20% identify as Democrats or Democratic-leaning independents. In addition, nearly six in ten (59%) held favorable views of Democratic candidate Biden at the time of the poll compared to 46% who held favorable views of President Trump. One-fourth of these voters had favorable views of both candidates.
• The voters who participated in the 2020 the KFF/Cook Political Report Sun Belt Voices are representative of the demographics of all voters who voted in the 2020 election. However in each state, the poll underestimated support for President Trump. This analysis provides some insight into better mining of voter files to better understand who we missed in our polling and how to better reach these voters in all of KFF polling going forward.

Who Actually Voted?

According to the United States Election Project, 2020 was a high turnout election in each of the three states included in the Sun Belt Voices Project with 65.3% of voters in Arizona voting in the presidential election, 71.2% of Florida voters, and 71.2% of North Carolina voters. Participating in a pre-election poll is strongly correlated with actual voting in an election and this holds true in this project. Ninety-three percent of survey respondents voted in the 2020 election including 93% of Arizona participants, 94% of Florida participants, and 94% of North Carolina voters. If we expand this analysis to our entire sample (including those who were contacted but did not participate in the survey), three-fourths of all voters who were contacted to participate voted in the 2020 election.¹ 

Who Were The New Voters In 2020?

The 2020 election saw a surge of new voters, with a record breaking 159 million Americans voting in the general election compared to 138 million votes just four years earlier. This surge can likely be attributed to a combination of things, including the increased access with many states allowing ballots to be cast by mail for the first time and waves of political activism. This analysis of our Sun Belt Voices Project look at one segment of new voters – those voters who stayed home in 2016, despite being eligible to vote, but chose to cast a ballot in 2020. One quarter (26%) of the voters in the 2020 general election in Florida, North Carolina and Arizona were low propensity voters—voters who had been eligible in 2016 (at least 22 years old in 2020) but did not vote in 2016.² 

A lot of attention around the 2020 election was given to Hispanic voter turnout, as some polls underestimated Hispanic support for incumbent Donald Trump. According to our analysis, one-third of Hispanic 2020 voters were low propensity voters, meaning they turned out to vote in 2020 but did not in 2016. If we include those who were newly eligible due to age, half of Hispanic voters (47%) who voted in 2020 in Arizona, Florida, or North Carolina had not voted in the previous presidential election. About one quarter White (24%) and Black (25%) 2020 voters were low propensity voters. About half (53%) of Hispanic voters voted in both the 2020 and 2016 election, compared to seven in ten Black (70%) and White (72%) 2020 voters.

According to this analysis, neither political party had the advantage among this group of new 2020 voters, with about one quarter Democratic voters and one in five Republican voters being in this low propensity category, however the Democratic Party did have a slight advantage among newly eligible 2020 voters. Eight percent of 2020 Democratic voters were newly eligible, meaning they recently turned 18 and were able to vote in their first presidential election, compared to 4 percent of 2020 Republican voters.

Three in ten (28%) of younger adults who had been eligible to vote in 2016 (ages 22 to 29) voted for the first time in 2020. Those ages 65 and older were least likely to be low propensity voters, with about one in six (17%) of these voters not voting in 2016 as well.

In Arizona and North Carolina, around four in ten low propensity 2020 voters (who had been previously eligible to vote but had not) had said they were “definitely going to vote” for President Biden, compared to about three in ten who said they same about Donald Trump. In Florida, these low propensity voters were divided in their support for each candidate. Leading up to the election, our polling similarly found Hispanic voters in Florida were more divided in candidate support.

How Did Voters cast their Ballots?

While voting by mail in Arizona was a widely used practice before the 2020 election, it was less common in Florida and only become available in North Carolina leading up to the 2020 election. Two-thirds of 2020 voters who participated in the Sun Belt Voices Project cast absentee ballots while the remaining shares either voted early in-person (22%) or vote in-person on Election Day (11%).

One of the major focuses of 2020 pre-election polls was to gauge how voters planned on casting their ballots during a global pandemic. Our analysis found that for many voters, their actual voting method did not exactly match their self-reported plans on voting method back in September. For example, while four in ten of those who ended up voting absentee said this was their intention, one in five had planned to either vote early in-person (19%) or had planned to vote in-person on Election Day (22%). Three-fourths of those who voted in-person had planned to do so back in September (77%) while those who voted early in-person had previously intended to vote various ways including in-person on Election Day (32%), by absentee (20%), or as they did – early in-person (38%).

While we do not know why many voters did not vote in the way they had planned to back in September, our analysis finds larger shares of voters across both political party and within different racial and ethnic groups decided to vote absentee than they had originally planned. Half (48%) of Democratic voters and one in four (23%) Republican voters had said they would vote absentee, while three in four Democrats (74%) and six in ten (62%) of Republicans actually voted using an absentee ballot. In addition, considerably larger shares of White voters, Black voters, and Hispanic voters voted absentee than originally planned to back in September.

This increase in the share of voters who voted absentee from who intended to vote absentee back in September may be due to an increase in trust in mail-in voting over the course of the 2020 election as well as increased access to absentee voting in the Florida and North Carolina.

Nearly seven in ten (69%) of new 2020 voters voted absentee (through the mail). Seven in ten (72%) low propensity voters took advantage of absentee voting, and an additional one in five voted early in person. Eight percent of low propensity 2020 voters voted in person on election day. Compared to low propensity voters, a slightly smaller share of total voters voted absentee. Early and absentee voting may have expanded accessibility, leading to an increase in voting among groups that had not previously voted.

Motivation And Intention Of Voters, New Voters and Non-Voters

Our analysis allows us to provide some insights into the views of voters who decided not to vote in the 2020 election, and it does not appear that anything happened in the last weeks of the 2020 presidential campaign that drastically impacted voters’ motivations or intentions. When we look at the 229 voters who participated in the Sun Belt Voices survey but who ended up not voting in the 2020 election, we find six weeks prior to Election Day about one-fifth (22%) of them had said they were “undecided” about who they were planning to vote for in the presidential election, compared to 9% of those who voted in the 2020 election. In addition, 22% of non-voters also said they were “less motivated” to vote in 2020 compared to 2016 (compared to 6% of voters who voted in 2020), as well as said their chances of voting in the 2020 election were 50-50 or less. One in four (26%) of these 2020 non-voters voted in 2016 compared to 68% of 2020 voters. Majorities of both groups (voters who voted and those who did not) said they were voting for a specific candidate and were enthusiastic about their vote choice.

On the other hand, 91% of voters who voted in the 2020 election reported they were “absolutely certain to vote” back in September and 78% of them reported being enthusiastic about their vote choice for either President Biden or President Trump.

Worries about voter suppression, voter fraud, or technical problems were not strong factors in voters’ decisions on whether or not to vote. In addition, it appears concerns around the coronavirus did not drastically impact decisions to vote, maybe due to the expanded access to mail voting, with similar shares of voters and non-voters saying they were worried they may be exposed to coronavirus while voting.

Looking again at low propensity voters who ended up voting in the 2020 general election, one reason for this decision can be attributed to enthusiasm about their vote choice (86%) and higher motivation to vote compared to 2016 levels (66%).

Who Were the Late Deciders?

Yet, while motivation to vote for a specific candidate is a strong predictor of the likelihood that a voter would cast a ballot, more than three-fourths of voters who reported being “undecided” in their responses to the Sun Belt Voices Project conducted in early September ended up voting in the 2020 presidential election.

While we do not know which candidate they chose to vote for, our analysis finds that half of these undecided voters identify as political independents (53%), one quarter (27%) identify as Republicans or Republican-leaning independents and one in five (20%) identify as Democrats or Democratic-leaning independents. In addition, among the group of initial undecided voters who ended up casting a vote in the 2020 presidential election, nearly six in ten (59%) held favorable views of Democratic candidate Biden at the time of the poll compared to 46% who held favorable views of President Trump. One-fourth of these voters approved of both President Trump and now-President Biden back in September.

What Motivated Voters In 2020?

When you examine the motivations and attitudes of voters who voted in the 2020 election, the top issues for voters are the same as we reported in the initial Sun Belt Voices Project analysis. The economy was the most important issue in deciding their vote for president, followed by criminal justice and policing, the coronavirus outbreak, health care, race relations, and immigration.

Similarly, low propensity voters said that economy was the most important issue in deciding their vote for president (32%), followed by the coronavirus outbreak (17%), criminal justice and policing (15%), health care (14%), race relations (13%), and immigration (5%).

This analysis also finds that the candidates’ advantages on key electoral issues among voters match their advantages in our pre-election polling as well as our analysis of the AP VoteCast data. Across most issues leading up to the 2020 general election, President Biden had the advantage among both voters who cast their ballot for the first time and overall 2020 voters; the economy is the exception with President Trump having the advantage on this issue with both sets of voters (+6 percentage points among low propensity voters and +8 percentage points among all 2020 voters).

Low propensity voters trusted Biden by larger margins, saying they trust Joe Biden to handle health care (+11 percentage points, +8 percentage points among all 2020 voters), race relations (+21 percentage points, +15 percentage points among all 2020 voters), the coronavirus outbreak (+16 percentage points, +9 percentage points among all 2020 voters), immigration (+9 percentage points, +2 percentage points among all 2020 voters) and criminal justice and policing (+5 percentage points, +2 percentage points among all 2020 voters).

How Did Our Methodology Do In Representing Voters?

One of the main narratives out of the 2020 election cycle was that public opinion polls underestimated support for President Trump in key states, including the three states included in the Sun Belt Voices Project. While the KFF/Cook Political Report partnership project was conducted more than a month prior to the election and was not designed to determine which candidate was leading in each of the key states, it is also our intention to ensure that the voters included in our sample are representative of the voters who ended up voting in the 2020 election.

Our methodology was designed in an effort to account for many of the deficits of polling from the 2016 presidential election. We started by generating a probability-based sample among all registered voters in each of the three states, contacting 31,500 voters (10,500 in each state) to participate in this project. We added extra incentives and outreach for key voting groups who had historically been underrepresented in election polls including Republicans, white voters without a college degree, and Hispanic voters. We allowed voters to participate in the survey using their preferred mode (online or over the phone), collecting responses from 1,298 voters in Arizona, 1,009 voters in Florida, and 1,172 voters in North Carolina. Finally, during the weighting stage, we adjusted the data so that Republicans and Democrats were represented in proportion to their share of the voter population as well as both 2016 and 2018 voter turnout in order to account for any additional partisan nonresponse bias.

Our analysis finds that these extra efforts as well as post-stratification weighting did a good job at estimating partisan turnout, turnout among Black and Hispanic voters, and correctly gauging the share of non-college educated white voters who voted in 2020. When we limit the analysis to just those who voted in the 2020 election (3,250 voters who participated in the survey and 24,468 voters who we contacted to participate), we find no meaningful differences by race/ethnicity, education, or partisanship among our weighted results to the entire sample of Sun Belt Voices voters.

In addition to this, our analysis finds both the mode and the sampling frame didn’t result in demographically different groups of voters. Samples from both the online completes and listed phone numbers in the Sun Belt Voices Project were similar to voters overall, with one third being Democrats or Republicans, and similarly distributed across education levels and race and ethnicity. Despite this, in each of the three states, our original Sun Belt Voices data overestimated Biden’s advantage in the states ranging from 3 percentage point difference in North Carolina to 5 percentage points in Arizona underestimating voter preference for President Trump. This is regardless of whether we limit our analysis to just voters who turned out in the 2020 election, those who participated in the survey online, or those who had listed phone numbers in their voter file records.

As pollsters prepare for the 2022 election cycle, more work is needed to better understand how polling’s failure to include or appropriately weight for a certain group of voters produced error that could explain a large portion of the polling error during the 2020 election. A lot of this work is already being done and was presented at the 2021 AAPOR Conference last week but as of now, there are still more lingering questions to be answered.

1. Individual voter turnout data for both respondents in the Sun Belt Voices Project and the entire Sun Belt Voices sample was provided by L2 with the assistance of SSRS. ↩︎
2. Respondents to the poll supplied their age at the time they took the survey in late August to early September 2020, but not their birth date. Because of this, 15 respondents who were under 22 years old at the time they completed the survey and voted in the 2016 election were dropped from this analysis. ↩︎

Introduction

Telehealth, the provision of health care services to patients from providers who are not at the same location, has experienced a rapid escalation in use during the COVID-19 pandemic, among both privately-insured patients and Medicare beneficiaries. Before the pandemic, coverage of telehealth services under traditional Medicare was limited to beneficiaries living in rural areas only, with restrictions on where beneficiaries could receive these services and which providers could be paid to deliver them. Soon after the federal government declared a public health emergency due to COVID-19 in early 2020, Congress and the Centers for Medicare & Medicaid Services (CMS) expanded traditional Medicare’s coverage of telehealth services in order to make it easier for beneficiaries to get medical care and minimize their exposure to coronavirus in health care settings. When the public health emergency ends, however, Medicare’s coverage of telehealth services will revert back to the more limited availability that existed before the pandemic, unless policymakers take action to extend the expanded coverage.

In light of the rapid, but time-limited, expansion of telehealth coverage under traditional Medicare, this brief provides an overview of the changes made during the COVID-19 pandemic to Medicare’s coverage of telehealth. It also presents new analysis of Medicare beneficiaries’ utilization of telehealth between the summer and fall of 2020, and discusses issues and questions related to extending telehealth coverage under traditional Medicare beyond the public health emergency. Our analysis of beneficiaries’ use of telehealth services is based on survey data of Medicare beneficiaries living in the community from the CMS Medicare Current Beneficiary Survey (MCBS) Fall 2020 COVID-19 Supplement. All differences reported in the text are statistically significant, unless otherwise noted. (See Data and Methods for details.)

Key Findings

• Among the vast majority of Medicare beneficiaries with a usual source of care (95%), such as a doctor or other health professional, or a clinic, nearly two-thirds (64% or 33.6 million) say that their provider currently offers telehealth appointments, up from 18% who said their provider offered telehealth before the pandemic. But nearly a quarter of Medicare beneficiaries (23%) say they don’t know if their provider offers telehealth appointments, and this percentage is larger among beneficiaries who live in rural areas (30%).
• Among the 33.6 million Medicare beneficiaries with a usual source of care who reported that their provider currently offers telehealth appointments, nearly half (45%) said they had a telehealth visit with a doctor or other health professional between the summer (July) and fall of 2020. This translates to just over 1 in 4 (27% or 15 million) of all community-dwelling beneficiaries in both traditional Medicare and Medicare Advantage using telehealth during this time period (Figure 1).

• Reported telehealth use among beneficiaries who said their provider offers telehealth was higher among Medicare beneficiaries under the age of 65 who qualify for Medicare due to a long-term disability (53%), beneficiaries enrolled in both Medicare and Medicaid (55%), Black (52%) and Hispanic (52%) beneficiaries, and those with 6 or more chronic conditions (56%). For some groups, including Medicare-Medicaid enrollees and those with multiple chronic conditions, higher rates of telehealth use may be related to higher use of health care overall. There was no difference in reported rates of telehealth use between beneficiaries in traditional Medicare and Medicare Advantage (44% and 45%, respectively).
• Among Medicare beneficiaries who had a telehealth visit, a majority (56%) report accessing care using a telephone only, while a smaller share had a telehealth visit via video (28%) or both video and telephone (16%). The share of Medicare beneficiaries who had a telehealth visit using telephone only was higher among those age 75 and older (65%), Hispanic beneficiaries (61%), those living in rural areas (65%), and those enrolled in both Medicare and Medicaid (67%).

Background on Medicare Coverage of Telehealth and Changes under the COVID-19 Public Health Emergency

Before the COVID-19 pandemic, coverage of telehealth services under traditional Medicare was limited. Medicare paid for approximately 100 services provided by telehealth, and there were limitations on how these services could be delivered and which beneficiaries could access them. Such limitations do not apply in Medicare Advantage plans, which have flexibility to offer additional telehealth benefits not covered by traditional Medicare outside of the public health emergency (see below for more information). Prior to the pandemic, the utilization of telehealth among traditional Medicare beneficiaries was extremely low, with only 0.3% of traditional Medicare beneficiaries enrolled in Part B using telehealth services in 2016, accounting for only 0.4% of traditional Medicare Part B spending. Similarly, analysis of primary care visits in traditional Medicare found that only 0.1% of these visits were provided via telehealth before the pandemic in February 2020.

To make it easier and safer for beneficiaries to seek medical care during the COVID-19 pandemic, the HHS Secretary waived certain restrictions on Medicare coverage of telehealth services for traditional Medicare beneficiaries during the COVID-19 public health emergency, based on waiver authority included in the Coronavirus Preparedness and Response Supplemental Appropriations Act (and as amended by the CARES Act). The waiver, effective for services starting on March 6, 2020, significantly loosened coverage restrictions for telehealth under traditional Medicare during the public health emergency, as described below. The public health emergency was most recently renewed in April 2021, and, according to the Biden Administration, is expected to remain in place for the duration of 2021.

Which traditional Medicare beneficiaries can receive telehealth services and where?

Before the public health emergency, telehealth services were generally available only to beneficiaries in rural areas originating from a health care setting, such as a clinic or doctor’s office. Beneficiaries in urban areas were ineligible for telehealth services, and beneficiaries could not receive telehealth services in their own homes. During the public health emergency, beneficiaries in any geographic area can receive telehealth services, and can receive these services in their own home, rather than needing to travel to a “distant site” (i.e., a health care setting).

What technologies can traditional Medicare beneficiaries use to access telehealth services?

Under Medicare’s existing telehealth benefit, a telehealth visit must be conducted with two-way audio/video communications and the use of smartphones or audio-only telephones in lieu of video is not permitted. For the duration of the COVID-19 public health emergency, telehealth services can be conducted via an interactive audio-video system, as well as using smartphones with real-time audio/video interactive capabilities without other equipment. Additionally, a limited number of telehealth services can be provided to patients via audio-only telephone or a smartphone without video.

What type of providers can get reimbursed by Medicare for telehealth visits?

Before the public health emergency, only physicians and certain other practitioners (such as physician assistants, clinical social workers, and clinical psychologists) were eligible to receive Medicare payment for telehealth services provided to eligible beneficiaries in traditional Medicare, and they must have treated the beneficiary receiving the services in the last three years. During the public health emergency, any health care professional that is eligible to bill Medicare for professional services can provide and bill for telehealth services, and does not need to have previously treated the beneficiary. Also, federally qualified health centers and rural health clinics are allowed to provide telehealth services to Medicare beneficiaries during the COVID-19 public health emergency; these settings were not authorized as providers of telehealth services for Medicare beneficiaries prior to the pandemic.

What services can traditional Medicare beneficiaries receive through telehealth?

Before the public health emergency, traditional Medicare covered about 100 services that could be administered through telehealth, including office visits, psychotherapy, and preventive health screenings, among other services. During the public health emergency, the list of allowable telehealth services covered under traditional Medicare expanded to include emergency department visits, physical and occupational therapy, and certain other services. Some evaluation and management, behavioral health, and patient education services can be provided to patients via audio-only telephone.

Are there additional services, other than telehealth, that are delivered virtually and covered by traditional Medicare?

Separate from Medicare’s coverage of telehealth services, traditional Medicare covers brief, “virtual check-ins” (also called “brief communication technology-based services”) via telephone or captured video image, and E-visits for all beneficiaries, regardless of whether they live in a rural area. Both of these services, which were not amended during the public health emergency, are more limited in scope than a full telehealth visit. For example, virtual check-ins can only be reported by providers with an established relationship to the patient, cannot be related to a recent medical visit (within the past 7 days), and cannot lead to a medical visit in the next 24 hours (or the soonest available appointment, and payment is intended to cover only 5-10 minutes of medical discussion.

How does Medicare pay providers for telehealth services?

Before the public health emergency, Medicare’s payment for a telehealth service was the same regardless of whether it was provided in a non-facility setting, such as a clinician’s office, or a facility setting, such as a hospital outpatient department, and the payment rate was based on the lower amount paid to facility-based providers for a service delivered in person. (Under Medicare’s physician fee schedule, the payment to facility-based-providers for in-person services is lower than the payment to non-facility providers because Medicare makes a separate payment to facilities to cover practice expenses, such as physical space, medical supplies, medical equipment, and clinical staff time.) The rationale for using the lower facility payment amount for telehealth services was that practice expenses for the delivery of telehealth services should be lower than those for an in-person visit.

During the public health emergency, Medicare pays for telehealth services, including those delivered via audio-only telephone, as if they were administered in person, with the payment rate varying based on the location of the provider, which means that Medicare pays more for a telehealth service provided by a doctor in a non-facility setting than by a doctor in a hospital outpatient department. This also means that during the public health emergency, doctors in non-facility settings are receiving a higher payment for services provided by telehealth than they did before the public health emergency.

What do traditional Medicare beneficiaries pay for telehealth services?

Beneficiary cost sharing for telehealth services has not changed during the public health emergency. Medicare covers telehealth services under Part B, so beneficiaries in traditional Medicare who use these benefits are subject to the Part B deductible of $203 in 2021 and 20% coinsurance. However, the HHS Office of Inspector General has provided flexibility for providers to reduce or waive cost sharing for telehealth visits during the COVID-19 public health emergency, although there is no publicly-available data to indicate the extent to which providers may have done so. Most beneficiaries in traditional Medicare have supplemental insurance that may pay some or all of the cost sharing for covered telehealth services.

How is telehealth covered under Medicare for beneficiaries and providers participating in alternative payment modes?

Separate from the time-limited expanded availability of telehealth services, CMS has granted providers participating in some alternative payments models, including Next Generation accountable care organizations (ACOs) and Medicare Shared Savings Program ACOs, greater flexibility to provide care through telehealth, including billing for telehealth services provided to both urban and rural beneficiaries and to beneficiaries when they are at home. Telehealth flexibilities in the Next Generation ACO demonstration are granted via benefit enhancement waivers administered by CMS. From 2016-2018, few Next Generation ACOs received and implemented telehealth waivers (4 ACOs; 8% of all ACOs in the model).

How does coverage of telehealth services differ in Medicare Advantage?

Medicare Advantage plans have been able to offer additional telehealth benefits not covered by traditional Medicare outside of the public health emergency, including telehealth visits provided to enrollees in their own homes and services provided outside of rural areas. In 2021, virtually all Medicare Advantage plans (98%) offer a telehealth benefit.

Medicare Advantage plans are paid a capitated amount by Medicare to provide basic Medicare benefits covered under Parts A and B; legislative changes implemented in 2020 allow plans to include additional telehealth benefits beyond what traditional Medicare covers in their bids for basic benefits. Therefore, the cost of additional telehealth services offered by Medicare Advantage plans are reflected in the capitated payment that plans receive.

Medicare Advantage plans have flexibility to waive certain requirements with regard to coverage and cost sharing in cases of disaster or emergency, such as the COVID-19 outbreak. In response to the coronavirus pandemic, CMS has advised plans that they may waive or reduce cost sharing for telehealth services, as long as plans do this uniformly for all similarly situated enrollees. Many Medicare Advantage plans have waived or reduced cost sharing for enrollees for some or all services administered via telehealth during the public health emergency.

Who Has Used Telehealth Services During the COVID-19 Public Health Emergency?

Awareness of Telehealth Availability

As of Fall 2020, six months after the expansion of telehealth benefits in traditional Medicare for the COVID-19 pandemic, nearly two-thirds of community-dwelling Medicare beneficiaries who say they have a usual source of care (64%, or 33.6 million beneficiaries), such as a doctor or health professional, or a clinic, reported that their usual provider offers telehealth appointments, up from roughly 1 in 5 (18%, or 6.1 million) beneficiaries who said their usual provider offered telehealth before the pandemic (Figure 2; Table 1). (The majority of community-dwelling Medicare beneficiaries, 95% or 52.7 million, report having a usual source of care). Conversely, 13% of beneficiaries with a usual source of care said their provider does not currently offer telehealth, a substantial decrease compared to the 52% who said their provider did not offer telehealth before the COVID-19 pandemic.

While the reported availability of telehealth has increased during the pandemic, nearly a quarter of Medicare beneficiaries with a usual source of care (23% or 11.9 million beneficiaries) said they do not know if their usual provider currently offers telehealth appointments.

The reported rates of beneficiaries who say their provider currently offers telehealth was similar across most demographic groups (Figure 3). However, a smaller share of Medicare beneficiaries living in rural areas than those living in urban areas said their provider currently offers telehealth (52% vs. 67%, respectively), and a larger share of rural beneficiaries report not knowing if their usual provider offers telehealth appointments than beneficiaries living in urban areas (30% vs 21%, respectively).

A larger share of Black Medicare beneficiaries with a usual source of care (23%) say their usual provider does not currently offer telehealth appointments than White (12%) and Hispanic (15%) beneficiaries with a usual source of care. Additionally, a larger share of Medicare beneficiaries enrolled in both Medicare and Medicaid (19%) say their usual provider does not currently offer telehealth appointments than Medicare beneficiaries who are not enrolled in both Medicare and Medicaid (12%).

Use of Telehealth

Among the two-thirds of Medicare beneficiaries with a usual source of care who reported in the Fall of 2020 that their usual provider offers telehealth during the pandemic (33.6 million beneficiaries), nearly half (45%, or 14.9 million beneficiaries) reported having a telehealth visit since July 2020. Some groups of Medicare beneficiaries were more likely than others to report having a telehealth visit with a doctor or other health professional since July 2020, including Medicare beneficiaries under age 65 with long-term disabilities, Black and Hispanic beneficiaries, Medicare beneficiaries enrolled in both Medicare and Medicaid, and beneficiaries with multiple chronic conditions (Figure 4; Table 2).

Among Medicare beneficiaries who have a usual source of care and whose usual provider offers telehealth:

• More than half (53%) of beneficiaries under the age of 65 (who qualify for Medicare due to a long-term disability) had a telehealth visit, compared to 42% of those age 65 to 74 and 43% of those age 75 or older.
• A larger share of Black (52%) and Hispanic (52%) Medicare beneficiaries than White (43%) beneficiaries say they had a telehealth visit.
• More than half (55%) of beneficiaries enrolled in both Medicare and Medicaid had a telehealth visit, compared to 43% of Medicare beneficiaries not enrolled in Medicaid.
• A larger share of beneficiaries with 6 or more chronic conditions reported having a telehealth visit than those with zero or 1 chronic condition (56% vs. 33%), and half or more of Medicare beneficiaries with specific chronic conditions had a telehealth visit, including those with diabetes (50%), a heart condition (50%), emphysema, asthma, or COPD (54%), and depression (55%), and those who are immunocompromised (59%).
• A similar share of Medicare Advantage enrollees and beneficiaries in traditional Medicare had a telehealth visit since July 2020 (45% and 44%, respectively) (Table 2).
• Medicare beneficiaries who report having a telehealth visit between the summer and fall of 2020 account for 1 out of 4 Medicare beneficiaries overall (27%, or 14.9 million beneficiaries), based on the total population of community-dwelling beneficiaries, which also includes beneficiaries who said they did not have a telehealth visit, beneficiaries who do not know if their provider offers telehealth, and those without a usual source of care who were not asked about their use of telehealth (Figure 4, Table 2).

Notably, among Medicare beneficiaries with a usual source of care and whose usual provider offers telehealth, we found no significant difference between the share of rural and urban Medicare beneficiaries who had a telehealth visit (43% and 45%, respectively). However, based on the overall population in these groups, rural Medicare beneficiaries were less likely than urban beneficiaries to have a telehealth visit with a doctor or other health professional (21% vs. 28%, respectively). This difference is likely driven by the fact that rural Medicare beneficiaries were more likely than urban Medicare beneficiaries to say they do not know if their usual provider offers telehealth (30% vs. 21%, respectively).

Similarly, among Medicare beneficiaries with a usual source of care whose usual provider offers telehealth, we found that a larger share of Black and Hispanic beneficiaries had a telehealth visit compared to White beneficiaries (52%, 52%, and 43%). However, among the total Medicare population, the difference in the share of Black and White beneficiaries who reported having a telehealth visit was not statistically significant (30% vs. 26%), while a larger share of Hispanic beneficiaries than White beneficiaries had a telehealth visit (33% vs. 26%). For Black Medicare beneficiaries, this result is likely related to the fact that nearly a quarter of Black beneficiaries overall (23%) say their usual provider does not offer telehealth appointments, compared to 12% of White beneficiaries and 15% of Hispanic beneficiaries.

How Did Beneficiaries Access Telehealth Services?

Among Medicare beneficiaries with a usual source of care whose provider offers telehealth appointments, the majority of those who had a telehealth visit since July 2020 accessed the service by telephone (56%), compared to 28% who reported having a telehealth visit by video and 16% who used both telephone and video (Figure 5; Table 3). This may be related to the fact that while more than 8 in 10 Medicare beneficiaries report having access to the internet (83%), smaller shares say they own a computer (64%) or a smartphone (70%) (Figure 6, Table 4).

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There are notable differences by demographic characteristics in how beneficiaries have accessed telehealth services during the pandemic and the availability of technology that enables access to telehealth, for example:

• Two thirds (65%) of beneficiaries 75 and older had a telehealth visit that was telephone-only compared to just over half (52%) of those ages 65 to 74, findings that likely reflect the smaller share of Medicare beneficiaries age 75 and older who report having access to the internet compared to those ages 65 to 74 (74% vs. 89%), or owning a computer (56% vs. 74%) or smartphone (53% vs. 80%).
• Six in 10 (61%) Hispanic Medicare beneficiaries had a telehealth visit that was telephone-only, compared to 54% of White beneficiaries, likely related to the fact that a smaller share of Hispanic Medicare beneficiaries than White beneficiaries report having access to the internet (67% vs. 86%), and a much smaller share of Hispanic beneficiaries than White beneficiaries say they own a computer (34% vs. 71%). Similarly, just 42% of Black Medicare beneficiaries own a computer, compared to 71% of those who are White, but the difference in the share of beneficiaries reporting a telephone-only telehealth visit was not significantly different for Black and White beneficiaries.
• Beneficiaries who live in rural areas were more likely than those living in urban areas to report having a telehealth visit that was telephone-only (65% vs. 54%), likely reflecting lower rates of internet access for rural beneficiaries than urban beneficiaries (78% vs. 84%) and ownership of computers (58% vs. 66%) or smartphones (60% vs. 72%).

Looking to the Future: Expanding Medicare Coverage of Telehealth Beyond the Pandemic

Our analysis finds that 1 in 4 Medicare beneficiaries have had a telehealth visit during the COVID-19 public health emergency, representing a substantial increase in use since before the pandemic. Our finding that, among beneficiaries whose provider offers telehealth, a greater share of those with disabilities, with low incomes, and in communities of color have used telehealth suggests that the temporary expansion of telehealth coverage may be helping some of Medicare’s more disadvantaged populations continue to access needed care. At the same time, in light of our finding that a quarter of Medicare beneficiaries overall (and an even larger share of those in rural areas) do not know if their doctor currently offers telehealth, efforts to increase awareness of covered telehealth services under Medicare during the public health emergency could help to broaden its reach.

Currently, policymakers are considering a variety of proposals to expand some or all of the existing flexibilities surrounding telehealth services under Medicare beyond the public health emergency, and many have expressed support for doing so. Among the telehealth-related bills that have been introduced in the 117^th Congress include proposals to permanently cover some of the telehealth expansions provided during the public health emergency, expand Medicare-covered mental health services and evaluation and management services administered via telehealth, and expand the scope of providers eligible for payment for telehealth services covered by Medicare. Other bills are aimed at assessing the impact of expanded telehealth services on the quality of patient care and program spending.

Under Medicare’s existing telehealth benefit, a telehealth visit must be conducted with two-way audio/video technology, while under the current public health emergency waiver, a limited number of telehealth services can be provided to patients via audio-only telephone. Given that the majority of Medicare beneficiaries in our analysis reported accessing telehealth services by telephone only, an expanded telehealth benefit that requires two-way video communication could be a barrier to care for subgroups of the Medicare population that relied more heavily on telephones than video-capable devices during the pandemic.

MedPAC has recommended that Medicare continue a modified version of expanded telehealth coverage for another year or two after the public health emergency ends, giving Medicare time to assess the effects of telehealth use on total costs, access, and quality of care. During this additional time, MedPAC recommends that Medicare pay for specified telehealth services regardless of where a beneficiary lives; cover some additional telehealth services beyond those covered prior to the public health emergency if there is potential for clinical benefit; and cover audio-only telehealth visits if there is potential for clinical benefit. MedPAC has also recommended that payment for telehealth services after the public health emergency revert to the lower facility-based payment rate in effect before the pandemic, and that providers should not be allowed to waive or reduce beneficiary cost sharing.

Expanded coverage of telehealth beyond the public health emergency could affect the quality of patient care as well as program and beneficiary spending. Broadening telehealth coverage has the potential to improve access to needed care, but there is uncertainty as to whether it would lead to an overall increase or decrease in program spending. Some telehealth services may be substitutes for in-person care, such as a behavioral health care visit, though easier access to telehealth could lead to an overall increase in visits and costs. Other telehealth services may not fully replace the need for (or occurrence of) an in-person visit, such as a visit to evaluate a skin rash or where lab work is determined to be needed. In building evidence on the cost and quality impacts of telehealth use in Medicare, the Administration could also potentially gain insights based on telehealth use by enrollees in Medicare Advantage plans, or by testing different approaches through Center for Medicare and Medicaid Innovation models.

The potential expansion of telehealth coverage brings with it concerns about the potential for fraudulent activity. There have been several large fraud cases involving telehealth companies in recent years, most of which involved the submission of fraudulent claims for items, services, and tests to Medicare and other insurers that were never given or administered to patients. HHS’ Office of the Inspector General (OIG) is conducting several studies to assess the appropriateness of use of telehealth during the public health emergency, including an analysis of provider billing patterns in order to identify providers that could pose a risk for program integrity and an audit of telehealth services under Part B to assure that services are meeting Medicare requirements. MedPAC has recommended that Medicare apply additional scrutiny to outlier clinicians who deliver more telehealth services than others, as well as requiring in-person visits before clinicians can order high-cost equipment or services for beneficiaries.

The temporary expansion of coverage for telehealth services has allowed many people with Medicare to access medical care during the coronavirus pandemic. Given that the temporary waiver of restrictions on coverage of telehealth services under Medicare will come to an end with the expiration of the public health emergency, the question of whether and how to ensure continued access to these services, while balancing concerns about quality of care and spending, looms large.

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More than a year into the public health emergency, the COVID-19 pandemic continues to impact the lives of Americans including those living in the U.S. territories. Prior to the pandemic, the U.S territories – American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Puerto Rico, and the U.S. Virgin Islands (USVI) – faced an array of longstanding fiscal and health challenges that were exacerbated by recent natural disasters. Differences in Medicaid financing, including a statutory cap and match rate, have contributed to broader fiscal and health systems challenges for the territories. While additional federal funds have been provided over the statutory caps, these funds are set to expire at the end of September 2021. Without additional Congressional action, the territories will lose the vast majority of Medicaid financing which could result in reductions in coverage, services, and provider rates which could negatively impact the territories as they deal with the long-term health and economic consequences of the pandemic. This brief looks at how the pandemic is affecting the territories as well as issues related to the upcoming Medicaid fiscal cliff.

Health Status and Systems in the Territories Pre-Pandemic

Even prior to the pandemic, residents of the U.S territories experienced a range of health disparities compared to the states. For example, Puerto Rico and the U.S. Virgin Islands (USVI) both have higher rates of diabetes¹  when compared to the United States overall. American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), and Guam have higher rates of obesity,²  high blood pressure,³  and smoking (respectively) when compared to the United States overall.

Additionally, the health care systems in U.S. territories have faced longstanding challenges, including deferred repairs to hospital facilities⁴  and major provider shortage issues. Recruitment and retainment is difficult as salaries for providers in the territories are substantially lower than they are for providers in the U.S. even though providers in most territories must be U.S.-licensed.⁵  Constraints with providers as well as system capacity sometimes requires that patients get care off-island.⁶  For example, prior to building its own oncology center on-island, CNMI sent over 300 patients a year to Guam or Hawaii for care.⁷ 

These health care system challenges were greatly exacerbated by recent natural disasters that occurred pre-pandemic. Typhoons, earthquakes, mudslides, and volcanic eruptions throughout the territories have caused extensive damage to hospital facilities, increased rates of provider outmigration, and increased the overall number of patients and the number of patients with more complex mental and physical health needs.

Effect of COVID-19 and Vaccine Roll-Out in the Territories

Early in the pandemic, the U.S. territories struggled with COVID-19 testing limitations and therefore COVID-19 cases and deaths may be underreported. In March 2020, only Guam and Puerto Rico were able to perform COVID-19 testing in their public labs but faced limited capacity due to supplies and staff.⁸  The other three territories had to send their testing samples to Hawaii or to the mainland – leading to longer turnaround time for results – until they acquired their own testing and analysis equipment.⁹  While Puerto Rico did have public labs to perform testing, in the spring of 2020, it had the lowest per-capita testing rates¹⁰  compared to any state and struggled to obtain the necessary supplies in order to increase its testing capacity.¹¹  Guam, on the other hand, lacked staffing to administer tests.¹² 

The pandemic exposed pre-pandemic health system issues that remained after the natural disasters. With the surge in COVID-19 cases, most territories reached hospital and ventilator capacity quickly and needed to recruit health care providers, especially nurses, from the mainland United States or neighboring international islands.^13 ,14 ,15  For example, in September 2020 in Guam, when fatalities increased and as more providers left the island, island officials looked to recruit 100 nurses from mainland U.S. or nearby Philippines.¹⁶  An infusion of funds from the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) helped some hospitals purchase additional hospital equipment and personal protective equipment (PPE).^17 ,18 

Puerto Rico saw increases in the average daily number of cases in March and April 2021, while the other territories remained steady. American Samoa is the only U.S. territory to have no cases or deaths to date. Despite increases in March and April in Puerto Rico, recent data show substantial decreases in the average daily number of cases. As of May 12, 2021, Puerto Rico’s average daily cases per million were 90.6, compared to 38.4 per million in Guam and 5.0 per million in CNMI. The average daily cases per million in USVI began increasing in early May, and as of May 12, it is the only current territory to surpass the U.S. rate of 111.9 cases per million (USVI had 139.3 cases per million population.¹⁹ 

Due to the previous surge in cases, Puerto Rico imposed more rigorous precautions. Early on, Puerto Rico issued overnight curfews and lock-down orders, which were punishable by fine or jail time.²⁰  In June 2020, businesses were fully reopened,²¹  but variations of the curfew have remained in place. In-person schooling reopened in March but was closed as cases surged in April²²  and beginning April 28, travelers must show proof of a negative COVID-19 test or face a $300 fine.²³ 

Similar to the states, CNMI, Guam, and USVI also imposed lockdowns, including some travel restrictions into the islands, but have slowly reopened businesses with varying degrees of capacity and service.^24 ,25  USVI has so far not altered its reopening plans to address the recent surge in cases in early May.²⁶  American Samoa, which has had no reported COVID-19 fatalities, had already implemented social distancing and school closures in December 2019 due to a measles outbreak.²⁷  In March 2020, in response to the pandemic, the government halted all flights in and out of the island, allowing only one weekly cargo flight in to provide medical supplies and food. Any American Samoa residents that left, including those needing medical services off the island during the pandemic, were not allowed to repatriate until early 2021.²⁸ 

The share of individuals ages 16 and older that have been fully vaccinated has more than doubled, and in some territories quadrupled, from March 1 to May 1, 2021 (Figure 1). As of May 1, every territory, except Puerto Rico and USVI, has fully vaccinated more than 30% of the eligible population. The territories have received vaccines at rates similar to states in U.S,²⁹  however some territories are administering a smaller share of delivered vaccines when compared to the U.S. overall. As of May 12, 2021, the share of delivered doses that had been administered in the U.S. was 78.5%, while CNMI and Puerto Rico’s shares were considerably lower (with 60.3% and 63.1% of delivered doses that have been administered, respectively). Issues related to administering vaccines could be caused by lack of staffing, challenges in reaching residents in more remote areas, or a lag in reporting.

The U.S. territories followed similar vaccination eligibility protocol to the U.S. with priority given to older populations, health care workers, and other essential workers. Additionally, all U.S. territories opened COVID-19 vaccinations to all adult residents earlier than President Biden’s April 19 deadline. Additionally, the territories utilized vaccination approaches that were tailored to their island’s needs to reach higher shares of their populations. For example, CNMI applied strategic outreach to the elders in the community,³⁰  while American Samoa, which only has one public hospital, used a drive-through vaccination site as an additional means to reach a higher share of their population.³¹ 

Key Financing Issues for the Territories

Prior to the pandemic, the most of territories experienced fiscal stress that was exacerbated by natural disasters or emergencies. For example, USVI saw its economy declined by over 30% between 2008 and 2016, accompanied by population loss and job loss in certain industries, while Puerto Rico faced years of economic recession and debt, ultimately prompting the creation of the Financial Oversight and Management Board (FOMB). These economic challenges were exacerbated by the natural disasters which accelerated the outmigration of residents and health care providers, destroyed homes, schools, businesses and other infrastructure, and lead to the loss of revenue with reduced tourism and economic activity.

The structure of Medicaid financing for the territories has also contributed to fiscal stress. Unlike in the 50 states and D.C., annual federal funding for Medicaid in the U.S. territories is subject to a statutory cap and fixed matching rate. The territories’ federal matching rate (known as the federal medical assistance percentage, or FMAP) is fixed in statute, unlike the statutory formula for states, which is uncapped and adjusted annually based on a state’s relative per capita income. The U.S. territories’ FMAP rate is set to 55% (though it has been increased in the aftermath of natural disasters and the public health emergency), but if the matching rates were calculated using relative per capita income, all territories would receive a higher FMAP, likely at or close to the maximum allowable 83% matching rate. Notwithstanding temporary relief funds, once a territory exhausts its capped federal funds, it no longer receives federal financial support for its Medicaid program during that fiscal year. This places additional pressure on territory resources if Medicaid spending continues beyond the federal cap – making the effective matching rate lower than what is set in statute.

Over time, Congress has provided increases in federal funds for the territories broadly and in response to specific emergency events. Temporary funding can provide short-term relief, but also create fiscal funding cliffs that require ongoing Congressional action. The allotments for each of the territories for FY 2020 and FY 2021 are around seven to nine times the statutory levels as a result of additional funding added in the FY 2020 appropriation package and the Families First Coronavirus Response Act (FFCRA) (Figure 2). Puerto Rico was eligible for an additional $200 million in FY 2020 and FY 2021 contingent on a provider rate increase equal to at least 70 percent of what Medicare Part B would pay for services. In addition to increased federal funding, the traditional territory of 55 percent was increased to 76 percent for Puerto Rico and 83 percent for the territories through FY 2021 (with an addition increase of 6.2 percentage points as part of Medicaid fiscal relief available for all state and territories if certain maintenance of eligibility requirements are met). As noted in recent Congressional testimony, additional federal funding in Puerto Rico has been used to support increases in coverage, additional benefits (like hepatitis C treatment), and increased reimbursement for hospitals, physicians, and managed care plans.

While capped federal funding is often a constraint for the territories, territories have occasionally experienced difficulty putting up their share of funding that is necessary to draw down the federal funds. Loss of local revenue, especially revenue from tourism, both due to previous natural disasters and COVID-19 may impact the territories’ ability to use their federal funding. Increasing the federal match rate would assists the territories by requiring fewer territory funds to access to additional federal funding.

Unless Congress acts, the U.S. territories will lose over 80% of their funding and there will be a major Medicaid financing cliff in at the end of FY 2021. Without federal action, territories would need to make significant changes to their programs to cut Medicaid provider payments rates, benefits, or eligibility criteria while still managing the effects of the pandemic.

What to Watch Looking Ahead

New federal funds and efforts to provide vaccines will help address the pandemic. The American Rescue Plan Act provided $4.5 billion in Coronavirus State Fiscal Recovery Fund Payments that can be used to respond to the “negative economic impacts of COVID-19”³²  and $700 million for critical capital projects to “directly enable work, education, and health monitoring in response to COVID-19”³³  that may help alleviate some economic challenges for the islands.

The expiration of temporary Medicaid funding at the end of September 2021 will result in a major fiscal cliff if Congress does not act. The territories could lose the majority of federal Medicaid financing as the temporary funds make up more than eight in ten federal Medicaid dollars in each of territory. Without federal action, territories would need to make significant changes to their programs to cut Medicaid provider payments rates, benefits, or eligibility criteria while still managing the effects of the pandemic.

Congress may consider increasing the caps or more fundamental Medicaid financing changes such as eliminating the funding cap and revisiting how the FMAP is set. Increasing the funding caps could provide short-term relief. Congress may also consider proposals to eliminate Medicaid funding limits in the territories like, the Insular Area Medicaid Parity Act (HR 265), the Territorial Equity Act of 2021, or proposals that would transition funding from the current structure to achieve parity with other state programs over time (like HR 3371 from the last Congress that would achieve Medicaid financing for Puerto Rico over 10 years). Temporarily increasing the spending caps in the territories could avert the upcoming fiscal cliff; however, such action could also create another fiscal cliff in the future and create uncertainty in the availability of federal funding longer term without more permanent financing changes.

1. Puerto Rico data are available for 2019. U.S. Virgin Islands data are available for 2016. ↩︎
2. National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), How CDC Prevents Chronic Diseases and Promotes Health for US Territories and Affiliated Pacific Islands (Atlanta, GA: Centers for Disease Control, April 2019), https://www.cdc.gov/chronicdisease/resources/publications/factsheets/island-health.htm ↩︎
3. Ibid. ↩︎
4. U.S. Army Corps of Engineers, Facilities Condition Assessment Guam Memorial Hospital (Washington, D.C.: U.S. Army Corps of Engineers, April 2020), https://www.doi.gov/sites/doi.gov/files/uploads/oia-guam-memorial-hospital-facility-assessment.pdf ↩︎
5. U.S. Department of the Interior, Office of the Inspector General, Insular Area Health Care: “At the Crossroads of a Total Breakdown” (Washington D.C.: U.S. Department of the Interior, Office of the Inspector General, September 2008), https://www.doioig.gov/sites/doioig.gov/files/2008-G-0040.pdf ↩︎
6. U.S. Department of the Interior, Office of the Inspector General, Insular Area Health Care: “At the Crossroads of a Total Breakdown” (Washington D.C.: U.S. Department of the Interior, Office of the Inspector General, September 2008), https://www.doioig.gov/sites/doioig.gov/files/2008-G-0040.pdf ↩︎
7. Averting A Crisis: Protecting Access To Health Care In The U.S. Territories, 117th Cong. (2021) (testimony of Congressman Gregorio Kilili Camacho Sablan). ↩︎
8. Peter Georgiev and Adiel Kaplan, “American Samoa’s coronavirus conundrum: No Way to test,” NBC News (May 2020), https://www.nbcnews.com/health/health-care/american-samoa-s-coronavirus-conundrum-no-way-test-n1167776 ↩︎
9. Ibid. ↩︎
10. Dánica Coto, “Missteps mar Puerto Rico’s response to coronavirus,” AP News (April 2020), https://apnews.com/article/e5ba6c2639ee52dad5e367d2228ac764 ↩︎
11. Patricia Mazzei, “Puerto Rico Lags Behind Everywhere Else in U.S. in Virus Testing,” The New York Times (August 2020), https://www.nytimes.com/2020/04/21/us/puerto-rico-coronavirus.html ↩︎
12. Haidee Eugenio Gilbert, “Lack of nurses could slow community testing as COVID cases rise again,” The Guam Daily Post (August 2020), https://www.postguam.com/news/local/lack-of-nurses-could-slow-community-testing-as-covid-cases-rise-again/article_6a7808b8-d79d-11ea-9cd1-370bce05a80d.html ↩︎
13. Emily Palmer, “Moored in a Fragile Paradise,” The New York Times (April 2020), https://www.nytimes.com/2020/04/17/travel/coronavirus-stjohn-caribbean.html ↩︎
14. Michael Walsh and Elsie Lange, “How the tiny Pacific island of Guam became one of America’s coronavirus hotspots,” ABC News Australia (September 2020), https://www.abc.net.au/news/2020-09-11/guam-hospitals-under-pressure-after-coronavirus-outbreak/12637704 ↩︎
15. Nicole Acevedo, “FEMA acknowledges Puerto Rico lacks rebuilt homes and a hospital to survive COVID-19,” NBC News (July 2020), https://www.nbcnews.com/news/latino/fema-acknowledges-puerto-rico-lacks-rebuilt-homes-hospital-survive-covid-n1234810 ↩︎
16. Michael Walsh and Elsie Lange, “How the tiny Pacific island of Guam became one of America’s coronavirus hotspots,” ABC News Australia (September 2020), https://www.abc.net.au/news/2020-09-11/guam-hospitals-under-pressure-after-coronavirus-outbreak/12637704 ↩︎
17. U.S. Department of the Interior, The Trump Administration is Supporting the People of the U.S. Virgin Islands (Washington, D.C.: U.S. Department of the Interior, 2020), https://www.doi.gov/sites/doi.gov/files/uploads/oia-covid19-wh-fact-sheet-usvi.pdf ↩︎
18. U.S. Department of the Interior, Commonwealth of the Northern Mariana Islands Uses Interior CARES Act Funding to Strengthen COVID-19 Emergency Preparedness and Response Capabilities (Washington, D.C.: U.S. Department of the Interior, July 2020), https://www.doi.gov/oia/press/commonwealth-northern-mariana-islands-uses-interior-cares-act-funding-strengthen-covid-19 ↩︎
19. Data are a KFF analysis of Johns Hopkins University Centers for Civic Impact for the Coronavirus Resource Center (CRC), https://github.com/govex/COVID-19/tree/master/data_tables/vaccine_data. Average daily number of cases are calculated as the average cases per million as a seven-day rolling average. For this analysis, the daily change in cases per million residents is averaged for the previous seven days. All data were pulled on May 12th, 2021. ↩︎
20. Edmy Ayala and Patricia Mazzei, “Puerto Rico Orders Coronavirus Lockdown. Violators Could Be Fined,” The New York Times (March 2020), https://www.nytimes.com/2020/03/15/us/coronavirus-puerto-rico.html ↩︎
21. Yanira Hernández Cabiya, “Dramatic economic reopening after 88-day lockdown,” Caribbean Business (June 2020), https://caribbeanbusiness.com/52221-2/ ↩︎
22. Associated Press, “Puerto Rico will close schools amid COVID surge,” NBC News (April 2021), https://www.nbcnews.com/news/latino/puerto-rico-will-close-schools-covid-surge-rcna632 ↩︎
23. Edmy Ayala and Patricia Mazzei, “Puerto Rico Just Had Its ‘Worst Moment’ for Covid-19,” The New York Times (April 2020), https://www.nytimes.com/2021/04/23/us/coronavirus-puerto-rico.html ↩︎
24. United States Virgin Islands, COVID-19 – Path to a New Normal (United States Virgin Islands, March 2021), https://www.vi.gov/covid/phases/ ↩︎
25. National Governors Association, Coronavirus State Actions (Washington D.C.: National Governors Association, July 2020), https://www.nga.org/coronavirus-state-actions-all/ ↩︎
26. Reopening efforts were analyzed on May 12th, 2021. At that time, USVI had not made any changes from its previous “Safer at Home” phase. ↩︎
27. Simon Romero, “A Place in the U.S. With No Covid-19? Look at American Samoa,” The New York Times (May 2020), https://www.nytimes.com/2020/05/06/us/coronavirus-american-samoa.html ↩︎
28. Associated Press, “American Samoa Repatriation Program Detects 5 Virus Cases,” U.S. News (January 2021), https://www.usnews.com/news/best-states/hawaii/articles/2021-01-28/american-samoa-repatriation-program-detects-5-virus-cases ↩︎
29. Rates were compared using “Total Doses Delivered Rate per 100,000” and data were analyzed on March 26th, 2021 and May 4th, 2021. See: Center for Disease Control, COVID Data Tracker (Centers for Disease Control, March 2021), https://covid.cdc.gov/covid-data-tracker/#vaccinations ↩︎
30. Steve Limtiaco, “CNMI outpaces United States in COVID-19 vaccine rollout,” Pacific Daily News (January 2021), https://www.guampdn.com/story/news/2021/01/06/cnmi-covid-19-vaccine-rollout-best-us-cdc/6574087002/ ↩︎
31. RNZ (Radio New Zealand), “Close to 24,00 Covid-19 vaccines rolled out in American Samoa,” RNZ (March 2021), https://www.rnz.co.nz/international/pacific-news/437798/close-to-24-000-covid-19-vaccines-rolled-out-in-american-samoa ↩︎
32. Manatt Health, The American Rescue Plan: An Overview of Medicaid Provisions and State/Local Relief (Manatt Health, March 2020), https://www.shvs.org/wp-content/uploads/2021/03/FINAL-ARP-Medicaid-and-State_Local-Relief-Deck.pdf ↩︎
33. Ibid. ↩︎

Over the past 15 years, there has been a national shift to making contraception more accessible outside of a clinical setting. New pathways include: allowing pharmacists to prescribe birth control, making contraception available via telehealth and efforts to making contraception available over the counter without a prescription. Many of these options are widely acceptable to women, with the majority of women comfortable with pharmacists prescribing birth control and making contraception available over the counter without a prescription. In recent years, a growing number of companies providing contraception through online platforms (“telecontraception”) have entered the market and are providing a new option for people to conveniently obtain contraceptive supplies that need a prescription without the need for an in-person visit. Some of these companies specialize in contraceptive care and others have expanded services into sexually transmitted infection (STI) testing and treatment, as well as other primary healthcare services. The COVID-19 pandemic has amplified the interest and need for such services and accelerated the evolution of these platforms over the last year as more people have sought ways to obtain care from home.

Research into these online platforms has been limited. One study focused on characteristics of patients seeking services through one telecontraception platform and found that women ages 18-24 and 25-34 make up the majority of telecontraception users and that combined oral contraceptives were the most dispensed contraceptives. Another study found that among clients using a primary care telehealth platform, women seeking contraception were more likely to use coupons and less likely to provide insurance information compared to women seeking other primary care services. Studies have also found these platforms are relatively safe and that for the most the part they adequately screen for birth control contraindications (such as high blood pressure and migraines with auras), but could further improve contraindication screenings.

The share of women nationally that relies on these companies to obtain contraceptives is still relatively small. The 2020 KFF Women’s Health Survey found that 4% of women 18 to 49 had ordered birth control from an online birth control platform. Women 18 to 35 (6%), Hispanic women (5%), and low-income women (6%) were more likely to use these platforms than older women (1%), white women (3%), and higher income women (3%).

Many of these companies are seizing on the opportunities to expand, especially during the pandemic, to more states, accept insurance and Medicaid, and offer additional services. Over the past year, companies have expanded to offer the newest contraceptive methods like Annovera, the one-year ring, and services like acne treatment and anxiety medication. Companies are reporting up to a 100% year-over-year increase during 2020 due to the pandemic.

KFF has been tracking these companies and the sexual health services they offer since the beginning of the COVID-19 pandemic and conducted a study to better understanding the policies and practices of 16 telecontraception companies in November 2020 through January 2021. We received responses from 13 of the 16 companies we reached out to. Of the 13 companies, three provided partial information (28%-48% complete) and 10 companies responded to nearly all of the questions. This report presents the results of that study and discusses the implications of the findings.

Overview

Customers access telecontraception platforms through web browsers or through phone apps. Clients create an account and fill out a health questionnaire that is meant to screen for birth control contraindications, such as a history of strokes, a recent pregnancy, high blood pressure and smoking status. Customers must also report a recent blood pressure reading. Depending on the state, a healthcare provider reviews these questionnaires once submitted or has a video consultation with the customer to determine whether the client is a good candidate for contraception. Research has found that telecontraception platforms generally screen adequately for these contraindications.

All telecontraception platforms offer oral contraceptives and many also offer the contraceptive patch and contraceptive ring. Platforms offer a variety of brands and generic equivalents, and most offer a $10 to $15 per month oral contraception option. Clients pick their preferred contraceptive method and depending on the company, can use private insurance or Medicaid to cover the prescription or pay out of pocket. Most companies also charge an additional consultation fee that covers the medical consultation and other services and is often not billed to insurance and must be covered out-of-pocket by the client. This can range from a $15 consultation fee to a $99 yearly membership that typically covers the medical evaluation and customer support for the duration of the prescription. Clients can obtain a new prescription for contraception or have an existing prescription mailed directly to their home or a local pharmacy for pickup.

Operations

Telecontraception Services

Telecontraception is marketed as a convenient way for people to quickly access a prescription for birth control without leaving their home. All the companies that responded said they provide asynchronous (e.g., store-and-forward) telehealth (n = 10), which involves a patient sending their information through a questionnaire or form that can be viewed by a medical provider at a later time. Seven of these companies also provide synchronous (e.g., live video-conferencing) telehealth services that involves real-time interaction between the patient and medical provider (Figure 1).

Four companies only require an online questionnaire to receive a prescription, one company requires a consultation via video call, and five companies require both an online questionnaire and consultation via video call, phone call, or text message (Figure 2). One of the companies that only requires an online questionnaire specified that they require a photo government ID and one company said they only require consultation with video in states when required, otherwise, they use an online questionnaire.

Staffing

PROVIDER TYPE AND PAYMENT

The number of providers working for telecontraception companies varied widely by company with a range of 10-154 providers working with each company. Of the eight companies that responded to this question, on average, online contraception companies were more likely to have medical doctors (MDs) on staff compared to other medical professionals, followed by nurse practitioners (NPs) (Figure 3).

A range of provider types work at telecontraception companies. Three companies employ only MDs as clinical staff. Three other companies have a much larger share of NPs compared to MDs (95%, 85%, and 80% NPs compared to 1%, 15%, and 10% MDs). One company is split evenly between MDs and Doctors of Osteopathic Medicine (DOs) (50% and 50%). There is another company that had a wide variety of providers, including 50% MDs, 30% NPs, 10% physician assistants (PAs), and 10% Doctors of Pharmacy (PharmDs). This is the only company that responded they were currently employing PharmDs and three companies employ PAs.

There was considerable variation in the arrangements that the companies used to pay their providers. Of the nine companies that responded about how their providers were paid, two companies said all of their providers were salaried employees, three companies said they had salaried providers and providers paid hourly, two companies said their providers were only paid hourly, and two companies said providers were paid per visit. One of these companies specified that their salaried employees were paid by the independent professional medical corporation with which the providers are affiliated.

TRAINING

The number of hours of training providers receive about prescribing birth control varied considerably ranging from one to fifteen hours. The company that responded one hour said training is one hour initially, followed by one hour per year. One company did not provide the number of hours of training their providers receive about prescribing birth control, but said every provider receives minimum required training, including ongoing training.

CONTRACEPTIVE COUNSELING AND REFERRALS

Nine of the ten companies that responded said their providers offer clients contraceptive counseling (Figure 4). Contraceptive counseling includes working with the client interactively to select the most appropriate contraceptive method for them. We asked, on average, how much time per visit providers usually spend doing contraceptive counseling. Two companies did not provide specific time ranges, only saying that it varies and the four companies that provided an amount of time said contraceptive counseling ranged from 2–15 minutes.

Of the nine companies that responded about referrals, eight companies said they offer referrals to another provider for clients seeking a contraceptive method that their company does not provide, or when a client is not eligible for hormonal methods based on their medical history. However, only one of the companies that responded to the questionnaire is affiliated with a brick-and-mortar health system or provider network to which they can refer clients. With additional follow-up, another company said they refer their patients to all the same places a typical primary care office would refer their patients to and help patients navigate the best place for them (e.g., in-network, geographical proximity, patient reviews). One company said they can direct clients to federally qualified health centers or other community-based organizations. One company said they did not offer referrals at all.

NEW PRESCRIPTIONS VS. ReFILLS

We asked what share of their new contraceptive clients were seeking a refill for their existing contraceptive method or were seeking a prescription for a new contraceptive method or different brand or formulation. Five companies responded and three companies said the majority of their clients were seeking a prescription for a new contraceptive method or different brand or formulation (percentage of clients: 100%, 70%, 70%) and two companies said their new contraceptive clients were split between those seeking a new prescription and those seeking a refill for their existing contraceptive method.

DISTRIBUTION

Telecontraception platforms offer two forms of delivery for contraceptives: at-home delivery via mail service and/or pick-up at a local pharmacy. From our tracker, most companies offer both at-home delivery and local pharmacy pick-up, and very few offer just one option. In our survey, the majority of companies said most clients fill their prescriptions via at-home delivery (n = 8), which makes these platforms convenient options, especially during a pandemic (Figure 5). Companies said it usually takes two to seven days for prescriptions to arrive at the client’s home and all the companies that do at-home delivery said they use the United States Postal Service for delivery, except for one company that uses DHL.

Two companies said that most of their clients fill their prescriptions via local pharmacy pick-up and that prescriptions are available for same-day pick-ups, making this a fast option if a client needs their contraception as soon as possible. Most telecontraception companies’ pharmacy pick-ups are available on the same day of the client consultation (n = 8). Two companies that mostly do at-home delivery said pharmacy pick-ups are not available for same day pick-up.

There is sizable variation in how these platforms work with pharmacies, both mail order and brick and mortar pharmacies. In order to deliver contraception to their clients’ homes, some companies use an in-house pharmacy, but the majority partner with outside pharmacies (Figure 6). At least one of the companies partnered with up to six pharmacies. The two companies that said most of their clients pick-up their contraceptives at local pharmacies partnered with larger pharmacy networks. One of the vendors reported partnering with 90,000 pharmacies and the other explained that they partner with one pharmacy delivery company, but are networked into most every major pharmacy in the U.S.

The majority of telecontraception companies distribute three months of oral contraceptives at a time (n = 8). However, there was variation. One company said, on average, they usually distribute one month of oral contraceptives at a time and another company said on average they usually distribute twelve months of oral contraceptives at a time. Some companies have providers that write prescriptions for a year of oral contraceptives, but they are only dispensed for one to three months at a time due to state and insurance limitations. Currently, only 19 states require that insurers cover a 12-month supply of oral contraceptives and that requirement is limited to fully insured self-regulated plans, not self-funded employer plans.

Clients Served

Since these telecontraception companies have been in business for differing periods of time (most of the companies started up between 2011 and 2019) and not all companies deliver and/or prescribe in all states, the number of contraceptive clients served by these companies varies widely; two companies were comparatively smaller, serving less than 10,000 contraceptive clients, while three companies reported serving 300,000+ clients (Figure 7).

Among all these companies’ clientele, contraceptive service customers account for 10%–100% of their total clientele. All the companies that responded said their contraceptive clients were 100% female. This could be because no prescription contraceptive methods are geared towards men and condoms are available for purchase at low cost over-the-counter. While there are companies that sell condoms online like Lola, the companies that we focused on for this study offered hormonal contraceptives. On average, the largest share of these companies’ clients are between the ages of 18 and 24, but the 25- to 30-year-old age group also accounts for one third of the market. (Figure 8).

Many of the companies are looking to diversify and expand their markets. When asked if there was a population their company would like to serve that they do not currently serve, responses included: Spanish  speakers, rural populations, LGBTQIA+ populations, and clients with Medicaid and insurance.

Availability Across State Lines

Many of these companies can be accessed in a number of U.S. states, and of the 13 companies in our study, five companies can prescribe contraception in all 50 states. Seven companies can function as a mail-order pharmacy and deliver contraception in all 50 states for those individuals that already have a prescription from their provider.

State telehealth laws and provider licensing across state lines were the top reasons that companies cited as to why they were not able to prescribe contraception to their clients in all 50 states. Two of the companies said that it was an administrative challenge for staff to bring on new states. One company said they were limited by the fact that their pharmacy partners don’t distribute in all 50 states (Figure 9).

For the six companies who said they could not deliver contraception by mail in all 50 states there was not a predominant reason. Two companies cited restrictive state telehealth laws. One of these companies also said they were limited by the fact that their pharmacy partners do not distribute in all 50 states and it is an administrative challenge for staff to bring on new states. One company said they do not have providers licensed in all 50 states and another responded that delivering contraception in all 50 states is in their product roadmap for future launch.

Marketing

Most telecontraception companies rely on a range of approaches to advertise and market their products and services. Some use organic searches from search engines like Google or Bing where people can search for their products (n = 11), paid searches or search engine marketing like Google ads (n = 9), or paid social media like Facebook, Twitter, and Instagram ads (n = 8) (Figure 10). One company said their consumers found out about their company through TV, podcasts, and influencers.

Services and Supplies

While all of the companies we surveyed provided contraception, many provided additional services to their clients, like urinary tract infection (UTI) treatment, STI diagnosis and treatment services, skin care and hair loss treatments, and other primary care services (Figure 11). Mental health services, and erectile dysfunction treatments were offered by four of the platforms and some also offer vitamins, COVID-19 tests and PrEP.

Oral contraceptives make up the largest share of their contraceptive service product lines by far, ranging from 70-93% with a mean of 87% across companies (Figure 12). A much smaller share of their contraceptive lines is for emergency contraceptive pills, the contraceptive ring and patch. A small fraction of their contraceptive lines includes Depo Sub-Q injections and female condoms.

The most popular contraceptive pill brand or generic alternative among customers using insurance and customers paying with cash was the combination pill Sprintec, which is a generic equivalent to Ortho-Cyclen. Apri and Vienva, combination generic pill equivalents to Desogen and Alesse respectively, were also popular among customers using insurance and cash. For customers using cash, companies also responded that Errin, a progestin-only generic equivalent to Ortho Micronor, and norethindrone, as well as Aubra EQ, a combination pill generic equivalent to Alesse were also popular (Figure 13).

We asked companies if there was a method of contraception they would like to carry that they do not currently offer and the reason why they did not currently carry it (Figure 14). Three companies said they would like to carry Depo-Sub-Q and one company responded that they currently do not carry it because the average co-pay and the self-pay cost are too high. Another company cited the same reasons for not carrying female condoms, and another wanted to carry male condoms, but said they are not reimbursed enough. One company said they would like to expand their contraceptive offerings to include Annovera, the 1-year vaginal ring, and Plan B or its generic alternative for emergency contraception and two companies would like to carry Phexxi gel, a non-hormonal prescription vaginal gel. Since our study was conducted, one of these companies now carries Phexxi gel. While these companies are primarily focused on short acting hormonal contraceptive methods, one company said they would like to work on patient flows that allow obtaining an IUD for single appointment insertion to streamline IUD adoption.

Payments for Services and Supplies

Since 2012, the Affordable Care Act (ACA) has required most private insurance plans to cover all FDA approved contraceptive methods and services without cost-sharing, although religious employers and employers with religious and moral objections to contraception are exempt from the coverage requirement. Additionally, the ACA also created a new Medicaid eligibility pathway for adults that also requires contraceptive coverage without cost-sharing. While these requirements do not apply to Medicaid pathways available prior to the ACA, KFF research has found that most states cover a broad range of contraceptive methods across all Medicaid pathways available in the state. Not all telecontraception platforms accept both private insurance and Medicaid, but the majority accept at least one form of insurance, and many serve clients willing to pay out-of-pocket for their contraception.

PRIVATE INSURANCE

We asked companies if they accepted private insurance and about the barriers they have encountered while working with private plans, and for those that do not accept private insurance, what were the obstacles that were preventing them from accepting it. Of the ten companies that responded to this question, eight accept private insurance and two companies do not (Figure 15). One company that does not accept private insurance cited multiple obstacles including that they had previously tried to work with private insurance, but experienced barriers; low reimbursement; excessive administrative burdens; the complexity of developing relationships with private insurance companies; and clients’ willingness to pay out-of-pocket. The other company that does not currently accept private insurance said they began with a self-pay model, but they are currently working on expanding to accept Medicaid and private insurance.

Among the companies that accept private insurance, three report that private insurance companies are unwilling to cover contraceptive mail order deliveries beyond the first few months, likely due to pharmacy contract limitations and competition by the private insurance companies’ internal mail orders. One company explained that Pharmacy Benefit Managers (PBM) place limits on refills from the telecontraception company and require patients to use their insurance company’s PBM’s mail order program. One company also said private insurance companies do not always cover a one-year supply of contraception when they prescribe one year of contraception, even when state law requires insurers in that state to cover a 12-month supply. One company cited prior authorization requirements and two cited copays as barriers they have experienced in trying to work with private plans. Another company also said that refills requested prematurely by clients result in coverage denials that mean patients must wait longer than they would like before getting their next refill. This same company said they are considered out of network (and therefore clients can be charged copayments) and the contraceptives they provide may not be on a private insurance company’s formulary also resulting in charges and lack of coverage.

MEDICAID

Fewer companies accept Medicaid, the state-federal health program for low-income people (6 of 10 that responded to this question). Of the four companies that do not accept Medicaid, half said they have tried to work with Medicaid but have experienced barriers. One of these companies also said that Medicaid’s telehealth policies are too restrictive. Two companies said that accepting Medicaid was too administratively burdensome and another two said the complexity of developing relationships with state Medicaid managed care organizations was a barrier to accepting Medicaid.

A major challenge to working with Medicaid that was cited by companies that currently accept Medicaid was the variation of Medicaid requirements across states, with each state Medicaid program having its own unique regulations and processes to enroll. One company said that in California, they have to contract with each county and the counties require them to be physically located within them, which makes their business model as a mail order company difficult. Another company similarly cited contracting challenges for mail order dispensing. One company also said that Medicaid requirements that the provider be located in a health facility to bill Medicaid also presented a challenge. This same company noted that low reimbursement rates for visits and oral contraceptive pills, restrictions on the number of packs that can be dispensed at one time to a patient, and requirement for a real-time (synchronous) video visit even in states that otherwise permit asynchronous care pose barriers to working with Medicaid.

Eight companies provided the distribution of payment methods that their current contraceptive clients use. One company’s contraceptive clients are 100% paying with cash – this company does not accept private insurance or Medicaid. Two other companies said the majority of their clients pay with cash. Three companies said half of their contraceptive clients use insurance and half use cash to pay for their contraception. Only two companies said the majority of their clients pay with insurance (Figure 16).

Of the nine companies that responded, four companies said they have relationships with manufacturers that offer their company a rebate, discount, or incentive for a particular contraceptive. Three out of the four companies said this allows them to offer these contraceptives at a lower price.

Change in Client Volume Since COVID

The COVID-19 pandemic has expanded interest and use of telecontraception companies, and many noted a sizable bump in business this past year. All of the companies that responded said their client volume has increased since the start of the COVID-19 pandemic. The majority of companies said their client volume had increased over 50% since the start of the COVID-19 pandemic (n = 6) when they responded in the winter of 2019 (Figure 17). One company had seen client volume increase between 25-50% and two companies had experienced client volume increases between 10-24%. Eight of the companies said they have seen the greatest relative increase in demand for oral contraceptives and one company had not seen an increase in demand for any particular method, but their client volume had increased over 50%.

Looking Forward

The rise of telecontraception platforms has created a new way for women of reproductive age to access contraceptives easily and quickly without having to visit a doctor’s office or leave their homes. This access has been particularly important during the COVID-19 pandemic as telehealth options have expanded. While many of the companies accept some form of insurance, barriers in working with insurance are cited frequently and people can end up paying out-of-pocket when they are entitled to no cost contraceptive services and supplies through their private insurance through the Affordable Care Act’s Contraceptive Coverage requirements. However, many women may be willing to pay out-of-pocket for the ease of a quick consultation and having their contraception sent straight to their home, without having to ever step foot in a clinic or schedule a telehealth appointment. These platforms are also available in all 50 states and could be affordable options for uninsured individuals that do not want or are unable to visit a Title X funded clinic or federally qualified health center to receive their contraceptive care.

While telecontraception may be a valuable option for some individuals, there is still an important role for bricks and mortar clinics that can provide the full range of contraceptive methods without cost-sharing to their patients and connect their patients to other primary care services. It will also be important that individuals who want to use telecontraception have access to quality contraceptive counseling, referrals if desired, and other primary care that may not be offered by all of these platforms. These companies may serve a small share of reproductive aged women right now but could become an important source of contraceptive care in the future, particularly for those individuals who may have difficulty accessing in-person care or prefer not to access care through a clinic. While telecontraception can provide a new pathway to contraception for many women, it does not necessarily ensure that people have access to the contraceptive method of their choice and that the financial and other structural barriers to that care are addressed.

Executive Summary

High and rapidly growing health care spending in the U.S. is a concern for consumers, employers, tax payers and policy makers. The relatively high prices paid by private insurers is one of the key factors fueling this trend, leading some policy makers to consider whether Medicare rates, or a multiple of Medicare rates, should be used to help control costs and address affordability concerns for people with private insurance. President Biden, for example, proposed during the campaign to establish a “public option” and reduce the eligibility age for Medicare from 65 to 60 to broaden coverage and lower costs. Democratic lawmakers in Congress have proposed similar legislation to provide more affordable health coverage by leveraging Medicare’s lower provider payment rates. However, some question whether a shift toward Medicare provider payment rates might adversely affect access to care and affordability for people who gain or change coverage under these options.

To inform this discussion, this analysis looks at the current experiences of Medicare beneficiaries ages 65 and older with respect to satisfaction and access measures and examines whether privately-insured adults ages 50 to 64 report access or cost problems at higher or lower rates than Medicare beneficiaries 65 and older. We do not attempt to model how shifts in coverage, and associated changes in provider payments, could change provider behavior and potentially impact access to care, the amount of health care services people use, satisfaction among patients, or affordability. This analysis draws on data from the 2018 Medicare Current Beneficiary Survey and the 2019 National Health Interview Survey (See Methods Appendix for additional information. All results reported in the brief are statistically significant).

Our analysis finds:

• Overall, the vast majority of adults 65 and older with Medicare coverage (94%) report being very satisfied or satisfied with the quality of their medical care and the availability of specialists.
• Most privately-insured adults ages 50 to 64 and Medicare-covered adults ages 65 and older report having a usual source of care in a setting other than an emergency department (96% for both insurance groups).
• A somewhat larger share of privately-insured adults ages 50 to 64 (16%) than Medicare-covered adults ages 65 and older (11%) report having cost-related problems, defined as delaying or forgoing medical care due to costs or having problems paying medical bills.
• The affordability gap is wider among adults in relatively poor health: one-third (33%) of privately-insured adults ages 50 to 64 report cost-related problems compared to one-fifth (20%) of Medicare-covered adults ages 65 and older.

Introduction

Health care spending accounts for nearly 18% of the U.S. economy and is projected to continue to rise for the foreseeable future. One factor driving this trend is the relatively high prices paid to health care providers for people who have private insurance through either an employer or purchased directly in the non-group market. Private insurers pay hospitals nearly double Medicare rates on average and pay physicians an average of 143% more than Medicare pays. These relatively high payments contribute to overall health care spending growth and higher per enrollee spending growth for people with private insurance. They also impact the premiums and out-of-pocket spending on deductibles and other cost-sharing that people pay.

Policymakers at the federal and state level have supported a range of proposals that aim to broaden coverage and improve affordability, including policies that adopt Medicare rates, or a multiple of Medicare rates. Recent KFF analysis found that health care spending for 60 to 64 year olds in large employer plans was 38% higher than 65 to 69 year olds with Medicare, suggesting that total health spending for these older adults could be lower, if, for example, 60 to 64 year olds in large employer plans were eligible to enroll in Medicare. However, some question whether a shift to Medicare rates for some privately-insured individuals would lead to lower levels of satisfaction and higher rates of access problems, or exacerbate affordability concerns. To inform this discussion, this analysis compares the experiences of privately-insured and Medicare-covered older adults.

Medicare beneficiaries and privately-insured adults with employer-sponsored and non-group coverage contribute to the cost of their health insurance and care through monthly premium payments, deductibles and other cost-sharing requirements at the point of service. People with Medicare pay monthly Medicare Part B premiums and may pay additional premiums for Medicare Part D prescription drug coverage, Medicare Advantage coverage, and supplemental insurance (if in traditional Medicare). In addition, Medicare beneficiaries incur costs for services in the form of deductibles, copayments and co-insurance that vary by type of service and source of coverage. There is no limit on out-of-pocket spending under traditional Medicare for benefits provided under Parts A and B, although most traditional Medicare beneficiaries have supplemental insurance (Medigap, retiree health or Medicaid) that covers much of these costs. In contrast, Medicare Advantage plans include a cap on out-of-pocket spending, but neither traditional Medicare nor Medicare Advantage provides a hard cap on prescription drug expenses. Premiums, cost-sharing requirements, and gaps in benefits (such as dental and long-term services and supports) contribute to relatively high out-of-pocket costs.

Most people with employer-sponsored coverage and private insurance in the non-group market are subject to varying amounts of annual premiums, deductibles, and fixed copayment or coinsurance amounts for services received and generally have coverage that includes a cap on out-of-pocket costs, which is a requirement of the Affordable Care Act. The specific premium and cost-sharing amounts vary, both across and within insurance types. Relatively high fees paid to providers contribute to higher costs per person and higher premiums and other out-of-pocket spending among enrollees. Further, because health needs and health spending rise with age, the financial burden of health care rises with age among non-elderly people with private insurance.

Even though private insurance typically reimburses physicians at a higher rate than Medicare, Medicare beneficiaries have broad access to providers. The vast majority (97%) of all physicians participate in the Medicare program, which means that they agree to accept the established Medicare payment rates, and very few (1%) physicians have formally opted-out of the Medicare program. Employer and non-group private health insurance plans rely more on networks that may restrict access to certain providers, as do Medicare Advantage plans, which cover 39% of beneficiaries.

This brief begins with a look at rates of satisfaction and access indicators among Medicare-covered adults ages 65 and older (including those enrolled in both traditional Medicare and Medicare Advantage). It then examines whether privately-insured adults ages 50 to 64 report better or worse access to care than Medicare beneficiaries ages 65 and older. It also compares cost-related problems for both groups. Access and affordability in private insurance and Medicare are driven by many factors, including provider participation, scope of benefits, and required cost sharing.

In this analysis, we do not attempt to model whether extending Medicare’s payment structure to a subset of people who are currently covered by private insurance, such as those ages 60 to 64, would affect provider participation in the program, the amount of health care services people use, or the ability of the health care system to meet demand for care. However, this brief does provide insight based on the experience of beneficiaries covered under the current Medicare program. A detailed description of our methodology is included in the appendix.

Findings

Our analysis finds the vast majority of Medicare beneficiaries ages 65 and older report high levels of satisfaction with the Medicare program and few access problems. When comparing older (65-plus) adults with Medicare to privately-insured adults ages 50 to 64, we find a larger share of privately-insured adults report cost-related problems, such as delaying getting medical care because of cost, needing medical care but not getting it because of cost, or problems paying or inability to pay any medical bills—a pattern that is particularly pronounced for those in relatively poor health. This may be counter to expectations because Medicare-covered adults ages 65 and older tend to be sicker and use more health services than privately-insured adults ages 50 to 64.

Overall, Medicare-covered adults ages 65 and older are satisfied with their care; few have trouble getting needed care

Most Medicare beneficiaries ages 65 and older report being satisfied with their care. The vast majority of Medicare beneficiaries ages 65 and older (94%) report being very satisfied or satisfied with the quality of their medical care, with no significant differences by race and ethnicity, gender, and metropolitan status, according to data from the 2018 Medicare Current Beneficiary Survey (MCBS). A slightly smaller share of Medicare beneficiaries in self-reported fair or poor health (91%) report being very satisfied or satisfied than those in self-reported excellent, very good, or good health (95%) (Figure 2, Table 1). The MCBS only includes Medicare beneficiaries, and does not include a comparison group of adults with private insurance. While the 2019 NHIS includes a comparison group of privately-insured adults, it does not include measures of satisfaction. A 2020 survey by the Medicare Payment Advisory Commission (MedPAC)  found that larger shares of Medicare beneficiaries ages 65 and older (88%) reported being very or somewhat satisfied with the overall quality of their health care than privately-insured adults ages 50 to 64 (82%).

Nearly 9 in 10 (87%) Medicare beneficiaries ages 65 and older report being very satisfied or satisfied with the availability of care by specialist, with no significant differences by race and ethnicity, gender, or self-reported health status (Figure 2). A slightly larger share of Medicare beneficiaries ages 65 and older in metropolitan areas (88%) report being very satisfied or satisfied with the availability of care by specialists than adults ages 65 and older in rural areas (83%) (Table 1).

Few Medicare beneficiaries ages 65 and older report trouble getting needed health care or forgoing needed medical care. A small share (5%) of all Medicare beneficiaries ages 65 and older report trouble getting needed health care and a similarly small share (5%) report that they had a problem for which they should have seen a doctor but didn’t (Table 1).

A somewhat larger share of Medicare-covered adults ages 65 and older in relatively poor self-assessed health report trouble getting needed health care (10%) or having a problem for which they should have seen a doctor but didn’t (11%) than beneficiaries in better health (4% for each measure). Somewhat larger shares of Black and Hispanic Medicare beneficiaries report trouble getting needed care (7% and 8%, respectively) than White Medicare beneficiaries (4%), though there are no significant differences by race and ethnicity in the shares of Medicare beneficiaries with problems for which they should have seen a doctor but didn’t (Table 1).

The vast majority of privately-insured adults ages 50 to 64 and Medicare-covered adults ages 65 and older have a usual source of care

The vast majority of privately-insured adults ages 50 to 64 and Medicare beneficiaries ages 65 and older report having a usual source of care. Analysis of 2019 data from the National Health Interview Survey (NHIS) finds that 96% of both privately-insured adults ages 50 to 64 and Medicare-covered adults ages 65 and older report having a usual source of care (Table 2).

Among those with a usual source of care, the majority of privately-insured adults ages 50 to 64 (89%) and Medicare-covered adults ages 65 and older (90%) report a usual source of care other than an emergency room or urgent care, such as a doctor’s office or health center. This is generally true without regard to race/ethnicity, gender, self-reported health status, and metropolitan status.

A larger share of privately-insured adults ages 50 to 64 than Medicare-covered adults ages 65 and older report affordability problems

A larger share of privately-insured adults ages 50 to 64 than Medicare-covered beneficiaries ages 65 and older report having cost-related problems (16% versus 11%, respectively) (Figure 3, Table 3). Cost-related problems include delaying getting medical care because of cost, needing medical care but not getting it because of cost, or problems paying or inability to pay any medical bills during the past 12 months.

The affordability gap between privately-insured adults 50 to 64 and Medicare-covered adults ages 65 and older is more pronounced among those in worse health. For example, among adults in fair or poor self-assessed health, one-third (33%) of privately-insured adults ages 50 to 64 report at least one cost-related problem compared to one-fifth (20%) of Medicare beneficiaries ages 65 and older. Additionally, among adults with 5 or more chronic conditions, the share of privately-insured adults ages 50 to 64 with cost-related problems (42%) is more than double the share reported by Medicare-covered older adults (19%).

Consistent with the overall findings, larger shares of 50 to 64-year-old privately-insured women, men, and people in both urban and rural areas report cost-related problems than their counterparts with Medicare. Notably, the shares of privately-insured Black and Hispanic adults ages 50 to 64 with cost-related problems are not significantly different from the share of Black and Hispanic Medicare-covered older adults reporting cost-related problems, although cost-related problems are more common among White privately-insured adults ages 50 to 64 than White Medicare-covered adults ages 65 and older.

However, within both private insurance and Medicare, larger shares of Black and Hispanic adults report cost-related problems compared to White adults with the same type of insurance. Among people ages 50 to 64 with private insurance, 21% of Black enrollees, 18% of Hispanic enrollees, and 15% of White enrollees report cost-related problems. Within Medicare, 23% of older Black beneficiaries, 17% of older Hispanic beneficiaries, and 9% of older White beneficiaries report cost-related problems.

Nearly half of privately-insured adults ages 50 to 64 report worries about the ability to pay medical bills compared to a third of Medicare beneficiaries ages 65 and older. A larger share of privately-insured adults ages 50 to 64 than Medicare-covered adults ages 65 and older report being very or somewhat worried about being able to pay medical bills if they were sick or had an accident (48% versus 33%). Again, the differences were larger for those in worse health or with more chronic conditions. Specifically, 64% of privately-insured adults ages 50 to 64 in self-assessed fair or poor health report being worried about paying medical bills compared to less than half (42%) of Medicare beneficiaries ages 65 and older in self-assessed fair or poor health. Among adults with 5 or more chronic conditions, the share of privately-insured adults ages 50 to 64 with worries about paying medical bills (66%) is larger than the share among Medicare beneficiaries ages 65 and older (39%). This pattern persists even among adults with fewer (3-4) chronic conditions (Figure 4, Table 3).

Larger shares of 50 to 64-year-old privately-insured women, men, and people in urban and rural areas report worries about their ability to pay medical bills than their counterparts ages 65 and older with Medicare. We also observe that among older adults with Medicare, larger shares of Black and Hispanic beneficiaries (43% and 44%, respectively) than White beneficiaries (30%) report worries about being able to pay medical bills. Additionally, among privately insured adults ages 50 to 64, a larger share of Hispanic than White adults report worries about paying medical bills (58% and 47%, respectively); the difference between privately insured Black and White adults ages 50 to 64 is not statistically significant. Across the two insurance groups, larger shares of privately-insured White and Hispanic adults ages 50 to 64 than Medicare-covered White and Hispanic older adults report worries about their ability to pay medical bills; the difference in the share of Black adults with worries about being able to pay medical bills is not statistically significant.

Discussion

Our analysis finds that most adults ages 65 and older with Medicare have relatively good access to care and are satisfied with the quality of the care they receive, consistent with previous analyses. Additionally, adults ages 65 and older with Medicare report comparable access to care as privately-insured adults between 50 and 64. These findings suggest that lower Medicare reimbursement rates relative to private insurance do not generally inhibit the ability of adults ages 65 and older to receive health care services.

These findings are consistent with past research, particularly analyses by the Medicare Payment Advisory Commission (MedPAC), which show that Medicare beneficiaries ages 65 and older had similar or better satisfaction rates and ability to find a new primary care physician or specialist compared to privately insured adults ages 50 to 64. Our analysis contributes to the body of evidence on the experience of Medicare beneficiaries compared to those with private insurance by also analyzing how cost-related problems compare between the two insurance groups. We find that a smaller share of adults 65 and older with Medicare than privately-insured adults ages 50 to 64 face cost-related problems, and these differences are more pronounced for people in worse health. However, a number of other studies have separately documented the financial burden of health care for people on Medicare, when premiums for supplemental insurance and uncovered services are taken into account.

Our primary focus in this analysis was to examine whether adults ages 50 to 64 with private insurance report different access to care or encounter cost-related problems in accessing care at different rates than adults ages 65 and older with Medicare. In comparing measures for certain subgroups, we also observe that Black and Hispanic adults within each insurance group often face higher rates of cost-related problems than White adults. This may be due in part to the fact that White adults tend to have more financial assets and lower utilization of costly-services such as inpatient stays and emergency department visits compared to Black and Hispanic adults. While there is additional help with premium and cost-sharing for Medicare beneficiaries and enrollees in the ACA Marketplaces with the lowest incomes and fewest assets, eligibility for that assistance may not fully account for financial vulnerability.

The higher rates of cost-related problems among privately insured adults ages 50 to 64 may be attributable to differences in benefit design, including deductibles, coinsurance rates and other factors, such as the scope of covered services. In addition, relatively high prices paid by private insurance for health care services contribute to higher out-of-pocket costs for enrollees. This is because the amounts paid by enrollees for health care services (e.g. deductibles and coinsurance) are often determined by price, and premiums are set to cover a set percentage of expected health care spending, compounding differences in cost-related problems that may be due to benefit design.

Any future health proposals that would build on Medicare or public coverage to rein in high health care costs, such as through a public option or by lowering the age of Medicare eligibility to 60, may help to mitigate cost-related problems that people with private insurance experience. These changes may be especially salient for people with greater health needs, including those in self-reported fair or poor health and those with multiple chronic conditions, who may utilize more services and incur higher out-of-pocket expenditures for their health care. While we did not attempt to model the impact of policies on provider behavior or access to care, our analysis shows that Medicare’s current reimbursement levels are not associated with cost or access problems.