Gender and age differences are revealed in a new analysis that finds nearly seven in ten (69%) young women ages 18 to 29 say the COVID-19 pandemic has negatively impacted their mental health, compared to smaller shares of women who are older and men across all age groups.

By mid-2020 about half (53%) of adults reported that worry and pandemic-related stress had negatively impacted their mental health. Now with millions of U.S. residents getting vaccinated against COVID-19, the latest analysis from the KFF COVID-19 Vaccine Monitor finds 47% of adults continue to report negative mental health impacts, and about a third of this group (or 15% of adults overall) report unmet needs for mental health care. The new report highlights recent data on the mental health impacts of the COVID-19 pandemic across gender, age, race, and income. Key findings include:

• Women, including mothers with children under 18, younger adults, and those in middle income groups are most likely to report their mental health has been negatively impacted as a result of the pandemic, compared to those 65 and older and men, including fathers with children under 18, who are least likely to report any mental health impact from the pandemic.
• The groups most likely to be worried that they or a family member may get sick from COVID-19 are women, Black and Hispanic adults, and younger adults. Among those expressing this worry, nearly six in ten say it has negatively impacted their mental health, showing a direct link between worry and negative mental health impact.
• Among mothers who say their mental health had been negatively impacted by the pandemic, nearly half (46%) report they did not get the mental health services or medications they needed, representing about one in four (27%) mothers overall.
• Among adults who did not get the mental health care they may have needed in the past year, some of the biggest reasons include not being able to find a provider (24%), inability to afford the cost (23%), or being too busy or unable to take off work in order to seek treatment (18%).

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

Private insurance companies are expecting to pay out $2.1 billion in rebates to consumers this fall, the second highest amount ever issued under the Affordable Care Act, according to a new KFF analysis.

The rebates, which are calculated based on the share of premium revenues that insurance companies paid out for health care expenses and quality improvement, are roughly $400 million lower than last year’s record high of $2.5 billion, but more than 50 percent higher than the $1.4 billion insurers sent back to policy holders in 2019.

Rebate amounts will vary by market. Individual market insurers account for the majority of the payments, with expected rebates of at least $1.5 billion, finds the analysis of data reported by insurers to the Centers for Medicare and Medicaid Services. Rebates in the small and large group insurance markets are expected to be $308 million and $310 million, respectively. The amounts are preliminary estimates, with final rebate data coming later this year.

The rebates are the result of insurance companies not meeting the ACA’s medical loss ratio threshold, which requires insurers to spend at least 80 percent of premium revenues (85% for large group plans) on health care claims or quality improvement activities. Most people in large group plans are in self-insured plans, which the MLR threshold rule does not apply to.

Not all policy holders are due rebates, but among those who are, this year’s rebates work out to roughly $299 per plan member in the individual market, $127 per member in the small group market and $95 per member in the large group market, according to KFF’s analysis. By law, insurance companies must begin issuing the latest rebates to eligible consumers later this fall.

One reason some companies failed to meet the threshold in 2020 is that the pandemic drove health spending and utilization down, as providers cancelled elective procedures and consumers opted to forego routine care out of fear of being infected. As a result, insurers generated higher levels of profits than they had anticipated when they set their 2020 premiums well before the pandemic emerged. Overall rebates would have been even higher had some insurers not taken steps to increase their claims costs relative to their premium income, including offering premium holidays and waiving certain out-of-pocket costs for enrollees, such as costs for telemedicine and for treatment for COVID-19. Claims costs also began to rise toward the end of the year during the winter surge in COVID-19 cases.

Rebates are calculated using a three-year average so the large rebates are not just a side effect of the pandemic. In the individual market, this year’s rebates are driven in large part by significant insurer profits in 2018 and 2019 (as rebates issued in 2021 are based on insurer financial performance in 2018, 2019, and 2020).

For more data and analyses about the pandemic, insurers’ financial performance and the ACA, visit kff.org.

In spite of a new price transparency rule that requires hospitals to publish the prices of common health services, comparing prices across hospitals remains challenging due to limited compliance with the law and a lack of standardization in the available data, a new KFF analysis finds.

The federal rule, which went into effect on January 1, 2021, aims to lift the veil on how much health plans pay hospitals for health services. To be compliant, hospitals must post payer-specific negotiated rates for medical services and products in two formats on their websites: in a machine-readable file that insurers, employers, health care providers, and other stakeholders can use to compare prices across providers, and in a consumer-friendly tool that allows patients to shop for lower-priced care.

Using data collected from large hospitals in all 50 states and the District of Columbia, the analysis finds limited compliance with the new federal rule. Only 35 of the 102 hospitals included in the analysis provide some payer-negotiated rates accessible to the public in a machine-readable file; only 3 provide payer-negotiated rates via consumer tools.

Even when hospitals are compliant, the lack of data standardization makes it difficult to compare prices across facilities. Many of the hospitals included in the analysis define and describe prices differently. For example, some hospitals include professional fees (e.g., for physician services) in the posted prices, other hospitals do not, and still others do not specify either way. Many hospital machine-readable files are inconsistently formatted and leave out key information, including the full range of payers and plans in a given region.

While the new price transparency data does not yet support price comparison across hospitals, it could in some cases facilitate analysis of price variation within a hospital. Using payer-negotiated rates from ten U.S. hospitals, the brief finds significant variation in the price of common services. For example, the price of a lower back MRI at a hospital in New Mexico ranged from $221 to $2,142 depending on the payer. The authors note that the available hospital data does not always clearly indicate the market in which a payer is operating; thus, an analysis of variation in prices by insurer market segment is not possible for most hospitals examined.

The brief is available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

A new issue brief examines compliance with a new federal price transparency rule and variation in payer-negotiated rates at U.S. hospitals. The analysis looks at the websites of the two largest hospitals in each state and the District of Columbia, and finds that a lack of consistency in the data and limited compliance among the hospitals sampled makes it difficult to compare prices across facilities.

The brief is available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Summary

With the distribution of the COVID-19 vaccine underway, ensuring equitable and rapid distribution to the U.S. population will be important for mitigating the disproportionate impacts of the pandemic for people of color, preventing widening racial health disparities going forward, and achieving broad population immunity. Reflecting underlying inequities, the COVID-19 pandemic has disproportionately affected American Indian and Alaskan Native (AIAN) people who account for over 5 million people in the U.S. At the same time, vaccination rates among AIAN people have been higher than average to date. This brief presents available data on COVID-19 vaccinations among AIAN people from federal and state sources and discusses factors contributing to success in these vaccination efforts. It finds:

Underlying inequities that existed prior to the pandemic contribute to AIAN people facing increased barriers to accessing health care and being disproportionately affected by the COVID-19 pandemic. Chronic underfunding of the Indian Health Service (IHS) relative to health needs and high uninsured rates contribute to barriers to health care among AIAN people. Existing social, economic, and health inequities have also led to higher rates of illness and death among AIAN people due to COVID-19.

Data available to date show that AIAN people are being vaccinated at a higher rate compared to other racial/ethnic groups. Federal data show that 32% of AIAN people had received at least one dose of a COVID-19 vaccine, compared to 19% of White people, 16% of Asian people, 12% of Black people and 9% Hispanic people of as of April 5, 2021.State data similarly find higher vaccination rates among AIAN people compared to other groups.

The high vaccination rate among AIAN people largely reflects Tribal leadership in implementing vaccine prioritization and distribution strategies that meet the preferences and needs of their communities. The high rates may also, in part, reflect the greater supply of vaccine doses delivered to the IHS relative to the number of people served compared to state vaccination programs. Tribes have supported and built on existing trusted community resources and providers to distribute vaccines. The success Tribes have achieved in vaccinating their communities provide lessons learned that may help inform broader vaccination efforts going forward.

Background: Health and Health Care for AIAN People

Under treaties and laws, the federal government has a unique responsibility to provide health care services to AIAN people. The IHS is the primary vehicle through which the federal government fulfills this responsibility for members of federally recognized tribes, who make up approximately 2.6 million of the over 5 million individuals who self-identify as AIAN nationwide. The IHS provides services directly, through Tribally operated health programs, and through services purchased from private providers. The IHS also funds Urban Indian Organizations to make health care services accessible to people who reside in urban areas, who include most of the AIAN population.

Due to longstanding limitations and underfunding of the IHS, AIAN people face disproportionate barriers to accessing health care. IHS services generally are limited to members of or descendants of members of federally recognized Tribes, and not all individuals who self-identify as AIAN belong to one of these Tribes. IHS historically has been underfunded to meet the health care needs of AIAN people, and access to services through IHS often varies across locations. Given the limitations of IHS, Medicaid and other sources of health insurance remain important for expanding access to care for AIAN people. However, as of 2019, 22% of AIAN nonelderly people were uninsured, the highest of all racial and ethnic groups (Figure 1).

The COVID-19 pandemic has disproportionately affected AIAN people. AIAN people face increased risk of exposure to the virus to due underlying social and economic factors and have higher high rates of health conditions that put them at increased risk for serious illness if they contract coronavirus. Reflecting these increased risks, AIAN people are nearly twice as likely to be infected with the virus, nearly four times likely to be hospitalized, and nearly two and half times as likely to die due to COVID-19 as their White counterparts, based on age-adjusted data (Figure 2).

COVID-19 Vaccination among AIAN People

The federal government is allocating COVID-19 vaccines directly to the IHS, and Tribal health programs and Urban Indian Organizations choose whether to receive vaccines directly from the IHS or through their respective state distribution mechanisms. As of March 15, 2021, 351 of the 609 IHS facilities, Tribal health programs, and Urban Indian Organization facilities had elected to receive vaccines directly through IHS; facilities can change their election. When Tribal health programs and Urban Indian Organizations elect to receive vaccines through the state, the CDC provides the state a “sovereign nation supplement” of vaccine doses. CDC data shows that as of April 5, 2021, nearly 1.5 million vaccine doses had been delivered to IHS, over 1 million doses had been administered via IHS, and more than 630,000 people had received at least one dose through IHS, making up over 30% of the population served by IHS.

Data available to date suggest that AIAN people are being vaccinated at a higher rate compared to other racial/ethnic groups. Data gaps limit the ability to have a complete picture of who is being vaccinated and how vaccination rates vary across groups. However, data available to date show that AIAN people are being vaccinated at a higher rate relative to other racial/ethnic groups. For example, federal data from CDC, which were available for about half of people who have received at least one dose as of April 5, 2021, suggest that over 720,000 AIAN people had received at least one COVID-19 vaccine dose, making up over 30 percent of the 2.2 million people who self-identify solely as AIAN (Figure 3). In contrast, these data show 19% of White people, 16% of Asian people, 12% of Black people, and 9% of Hispanic people had received at least one vaccine dose.

State-level data on vaccinations among AIAN people is limited. Only 36 states were reporting vaccinations among AIAN people as of March 29, 2021. Moreover, the state-reported data does not reflect vaccines administered through allocations received through IHS, and, as such, may understate vaccination rates and further limit the ability to calculate reliable estimates. However, data from several states show that AIAN people are being vaccinated at higher rates compared to other groups. For example, in Alaska, 22% of vaccinations have gone to AIAN people while they account for 15% of the population. The pattern is similar at the county-level. As of April 5, 2021, counties with high shares of AIAN people had a higher average vaccination rate (20%) when compared to the average across counties and counties with low shares of AIAN people (19% and 18%, respectively).¹ 

Factors Contributing to High AIAN Vaccination Rates

The high vaccination rate among AIAN people stands in stark contrast to the gaps in vaccinations for Black and Hispanic people observed to date. The underlying inequities and barriers to health care facing AIAN people similarly could have led to barriers to vaccination. However, experiences suggest that the autonomy provided to Tribes to design and implement vaccine distribution efforts among their communities has contributed to success in vaccinating the population. The high rates may also, in part, reflect the greater supply of vaccine doses delivered to the IHS relative to the population served compared to state vaccination programs. As of April 5, 2021, over 1.5 million doses had been delivered to IHS, which represents roughly nearly 75,000 per 100,000 people served by the IHS. Only 2 states and Washington DC had higher rates of doses delivered than the IHS, although the IHS rate of doses administered is lower compared to these states. Additionally, the availability of more complete race/ethnicity data for AIAN people receiving the vaccine, since many are receiving it through IHS, Tribal health, and Urban Indian Organization facilities, may also be contributing to the high rates. Federal and some state data have high shares of vaccinations with unknown or “other” race/ethnicity, which may affect vaccination rates across racial/ethnic groups.

IHS, Tribal health programs, and Urban Indian Organizations have autonomy and flexibility to implement priority and distribution strategies that meet the needs and preferences of their communities. The IHS developed a COVID-19 Vaccine Task Force (VTF) to advance plans for prioritization strategies, vaccine administration, distribution, data management, safety and monitoring, and communications. Consistent with the federal recommendations from the Advisory Committee on Immunization Policies (ACIP), IHS first prioritized health care workers and residents of long-term care facilities. Initial doses allocated to IHS were estimated to be sufficient for 100% of its health care workforce and residents of long-term care facilities. Like states, Tribes and Urban Indian Organizations have authority to make their own prioritization decisions. Many chose to prioritize elders and some, like the Standing Rock Sioux Tribe, prioritized speakers of native languages, to protect against further losses of culture and traditions that the pandemic has threatened. Several Tribes, including Chickasaw Nation, Cherokee Nation, and Lummi Nation, have already had so much success in vaccinating their priority groups that they have expanded distribution to include non-Native members of the public.

Tribes are building on and supporting existing trusted community resources and providers to distribute vaccines. Tribes are utilizing the networks and resources in the community and drawing upon years of experience to reach tribal members with various access barriers. For example, the Navajo Nation has vaccinated between 4,000 and 5,000 homebound citizens by collaborating with public health workers to reach those residents in rural communities. In Alaska, tribal health organizations relied on longstanding strategies developed to reach geographically isolated communities, including partnering with local pilots to transport pharmacists and vials of vaccines to such areas. In addition, many Tribes have established vaccine sign-up systems that match the resources and preferences of their populations. For example, media reports suggested that many Tribes have set up call centers to answer inquiries, book appointments, and reach out to people.

Tribes have launched tailored outreach and communication plans that share culturally relevant messages through trusted individuals in the community. A national survey of AIAN people conducted in late 2020 found that the majority were willing receive a COVID-19 vaccine and that the most commonly held motivation for getting a vaccine was a sense of responsibility to protect the Native community and preserve cultural ways. Regardless of willingness to get a vaccine, the most frequently reported concern about the vaccine was how fast the vaccine moved through clinical trials. Some Tribes have utilized fluent language speakers to address concerns about the vaccine among the community. For example, the Cherokee Nation prioritized Cherokee language speakers to create optimism and show that the vaccine was safe. Similarly, the Navajo Nation employed fluent doctors and health care professionals to serve as trusted sources of information on the vaccine.

Looking Ahead

Given the disparate impacts of COVID-19 on AIAN people and the barriers and challenges they face to accessing health care, ensuring access to the COVID-19 vaccine is particularly important. Data available to date show a high COVID-19 vaccination rate among AIAN people, largely reflecting the role of Tribes in designing and implementing vaccine distribution strategies that meet the needs and preferences of the communities they serve. The success Tribes have achieved in vaccinating their communities provide lessons learned that may help inform broader vaccination efforts going forward. The American Rescue Plan Act of 2021 provides IHS with an additional $600 million for vaccine efforts, $1.5 billion to trace COVID-19 infections, $240 million to establish and sustain a COVID-19 public health workforce, and $600 million for COVID-19 related facility improvements, which may further enhance Tribal vaccination efforts and their response to COVID-19.

1. KFF analysis of Centers for Disease Control and Prevention’s (CDC) COVID-19 Integrated County View data. Counties in which the share of AIAN people is above the national average of 0.7% were classified as counties with high shares of AIAN people. Of the 2,350 reporting counties, 617 fall into the high share of AIAN people category (26% of the counties). ↩︎

More than half (54%) of rural adults say they have already gotten at least one dose of a COVID-19 vaccine or will do so as soon as possible, as rural residents report less issues with both supply and access than those living in urban and suburban areas, according to a new KFF COVID-19 Vaccine Monitor report focused on rural America.

A somewhat larger share of rural residents (39%) than those living in urban (31%) or suburban (31%) areas say they have already received at least one dose of a COVID-19 vaccine.

However, there is a larger share of rural residents (21%) than urban (10%) or suburban (13%) ones saying they will “definitely not” get a COVID-19 vaccine, a gap largely explained by the concentration of Republicans and White Evangelical Christians who live there.

Among rural residents who say they will “definitely not” get vaccinated, nearly three quarters (73%) identify as Republican or Republican-leaning, and 4 in 10 (41%) identify as White Evangelical Christians.

“There’s nothing inherently unique about living in a rural area that makes people balk at getting vaccinated,” KFF President and CEO Drew Altman said. “It’s just that rural areas have a larger share of people in the most vaccine-resistant groups: Republicans and White Evangelical Christians.”

The new report examines in depth the vaccine-related views and experiences of a nationally representative sample of rural residents. Earlier Vaccine Monitor reports showed concerns about vaccine uptake among this group, which represents about a fifth of the nation’s population and has often reported difficulty accessing health care.

Among rural residents who have not received a COVID-19 vaccine, few (11%) say they have tried to get an appointment – half the share of those living in urban (21%) and suburban (22%) areas.

The large share of rural residents who say they will “definitely not” get vaccinated, and the relatively small shares who have tried to get an appointment or who hope to get vaccinated “as soon as possible” suggest the potential for vaccination rates in rural America to eventually lag behind those in urban and suburban areas.

Rural residents are more likely to say that their area has enough COVID-19 vaccine to serve their communities (58%) than residents of urban or suburban communities are (46% each). In addition, two thirds (68%) of rural residents say there are enough locations to get vaccinated, compared to just over half of urban (52%) and suburban (55%) residents.

Importantly, fewer Black rural residents (53%) than White (69%) or Hispanic (67%) rural residents say there are adequate vaccination locations in their communities. In addition, half of Black (47%) and Hispanic (52%) residents, compared to 6 in 10 White adults (59%), say there is an adequate supply of vaccine.

“Contrary to conventional wisdom, most rural residents have embraced the COVID-19 vaccine, with over half saying they’ve gotten it already or want to get it as soon as they can,” KFF Executive Vice President Mollyann Brodie said. “Most people in rural areas believe their communities have enough vaccine and places to get vaccinated, though fewer Black residents do, suggesting a gap in access.”

The report also captures the impact of a variety of potential incentives, messages, and pieces of information on vaccination uptake.

Similar to the general public, various incentives and messages are most effective in moving rural residents in the “wait and see” and “only if required” groups. For example, at least half of those in the “wait and see” group say hearing that the vaccines are nearly 100% effective at preventing hospitalization and death from COVID-19 (64%) or that scientists have been working on the technology used in the new COVID-19 vaccines for 20 years (52%) will make them more likely to get vaccinated.

Across the board, none of the messages or pieces of information were effective at moving those who say they will definitely not get vaccinated.

Other highlights include:

• Half of adults in rural areas (49%) who have received at least one dose of a COVID-19 vaccine say it took them less than 15 minutes to get to the vaccination site, similar to the share of urban and suburban residents who say so.
• Rural residents (40%) are less likely to say they are worried about themselves or their family members getting sick from coronavirus than urban (54%) and suburban residents (49%) are, and are more likely to believe the news has “generally exaggerated” the seriousness of the coronavirus pandemic (44%) than urban (27%) and suburban (33%) residents are.
• More (58%) rural residents view getting vaccinated as a personal choice rather than part of everyone’s responsibility to protect the health of others (42%). The reverse is true among urban residents, while suburban residents are more evenly divided.

Designed and analyzed by public opinion researchers at KFF, the KFF Vaccine Monitor: Rural America was conducted from March 15-29 among a nationally representative random digit dial telephone sample of 1,001 adults living in rural America, the margin of sampling error is plus or minus 4 percentage points. For results based on subgroups, the margin of sampling error may be higher. All comparisons to urban and suburban residents are from the KFF March Vaccine Monitor. The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and hesitancy, trusted messengers and messages, as well as the public’s experiences with vaccination.

A new issue brief reviews excess death rates in the U.S. and peer countries by age groups to examine how the pandemic has affected excess mortality rate among younger people. The analysis looks specifically at the excess deaths that arose in 2020 to examine how the age at death during the pandemic has differed between the U.S. and peer nations, and estimates the excess potential years of life lost (a measure of “premature excess death”) during the pandemic. The brief also explores racial disparities in the age of death in the U.S.The analysis is available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

A new KFF issue brief examines 2020 data on excess mortality – the number of deaths above what is expected in a typical year – and finds that among similarly large and wealthy nations, the United States had the highest premature excess mortality rate in 2020, indicating that younger people in the U.S. were more likely to have died due to the pandemic than younger people in other countries.

The excess mortality rate among Americans ages 15-64 was 58 per 100,000 people in the age group in 2020 – more than double that of the next closest peer nation, the United Kingdom (25 per 100,000).  Nearly half (48%) of excess deaths in the U.S. were among people younger than 75, compared to 18% for Belgium, a country with a comparable overall excess mortality rate.

The brief also estimates excess potential years of life lost (“premature excess deaths”) in the U.S. and peer nations. Excess potential years of life lost (up to age 75) is a measure of excess mortality and is used to compare differences in disease burden and longevity across countries. The analysis finds that the U.S. had 1,171 excess potential years of life lost up to age 75 per 100,000 people ages 0-74, which is over twice the rate of premature excess mortality in the next closest country, the U.K. (488 per 100,000 people). This approach, which follows OECD methods, may understate premature excess mortality in 2020, as excess deaths over age of 75 in 2020 were also premature compared to a typical year.

In comparison to a typical year, the U.S. lost an additional 3.6 million potential years of life in 2020. The high premature excess death rate in the U.S. was driven in part by racial disparities. American Indian and Alaska Native, Black, Native Hawaiian and Other Pacific Islander, and Hispanic people had over 3 times the premature excess death rate in the U.S. in 2020 than the rate among other groups. Thirty percent of the total excess potential years of life lost in the U.S. were among Black people, and 31% were among Hispanic people, rates disproportionate to their shares of the total U.S. population.

Prior to 2020, the U.S. already had the highest rate of premature deaths among peer countries. This analysis shows the gap in premature mortality rates between the U.S. and peer countries has increased due to the pandemic.

The analysis is available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.