The U.S. thus far has enacted six emergency supplemental funding bills, five of which were enacted in 2020 and one which was enacted in 2021, to address the COVID-19 pandemic:

• the Coronavirus Preparedness and Response Supplemental Appropriations Act (P.L. 116-123) enacted on March 6, 2020;
• the Families First Supplemental Appropriations Act (P.L. 116-127) enacted on March 18, 2020;
• the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136) enacted on March 27, 2020;
• the Paycheck Protection Program and Health Care Enhancement Act (P.L.116-139) enacted on April 24, 2020;
• the Coronavirus Response and Relief Supplemental Appropriations Act, 2021 (P.L. 116-260) enacted on December 27, 2020; and
• the American Rescue Plan Act of 2021 (P.L. 117-2) enacted on March 11, 2021.

While most of the funding in these bills has been for the domestic response, approximately $19 billion has been appropriated for global efforts, provided in four of the six bills – the Coronavirus Preparedness and Response Supplemental, the CARES Act, the Coronavirus Response and Relief Supplemental Appropriations Act, 2021, and the American Rescue Plan Act of 2021. The most recent bill, the American Rescue Plan Act, includes the most funding for the global response to date ($11.6 billion). The funding in these bills support the operations of U.S. agencies in other countries, including for repatriation of U.S. personnel, and funding provided directly to affected countries and international efforts. This data note tracks appropriations designated for international efforts in the emergency bills. It will be updated as needed.

Table 1 provides a list of the agencies and funding amounts specified for international efforts across each bill. Table 2 provides more details on this funding, including the expenditure period and a description of specific activities.

As of early March, just over half (52%) of frontline health care workers say they have received at least one dose of a COVID-19 vaccine, leaving 48% who have not, a new KFF/The Washington Post national survey of health care workers finds.

Most who work in hospitals (66%) and outpatient clinics (64%) say they have received a COVID-19 vaccine, compared to half who work in doctors’ offices (52%) or in nursing homes or assisted care facilities (50%), and a quarter (26%) of home health care workers. Similarly, seven in ten (68%) of those responsible for patient diagnosis and treatment like a doctor or a nurse report receiving a COVID-19 vaccine, compared to about four in ten of those who perform administrative duties (44%) or who assist with patient care such as bathing, eating, cleaning, exercising, and housekeeping (37%).

The findings related to vaccination intentions come from a new KFF/Post partnership survey examining the experiences and attitudes of frontline health care workers during the COVID-19 pandemic and appear in The Washington Post and in a KFF report. Additional findings focused on the emotional, physical and economic toll that the pandemic has taken on frontline health care workers will appear in future stories and reports.

Among the initial findings:

• The unvaccinated group of frontline health care workers includes some who either have their vaccination scheduled (3%) or plan to get vaccinated but haven’t scheduled it yet (15%). It also includes 3 in 10 who have either not decided whether they will get vaccinated (12%) or say they do not plan on receiving a COVID-19 vaccine (18%).
• A large majority of unvaccinated health care workers who either have not decided if they will get vaccinated, or say they do not plan to get vaccinated, say that worries about potential side effects (82%) and the newness of the vaccine (81%) are major factors in their decision making. These are the top concerns across the different demographic groups of unvaccinated health care workers including Black health care workers, Hispanic health care workers, and White health care workers.
• Among frontline health workers, half of Black workers, 45% of workers without a college degree, and four in ten Republican and Republican-leaning workers say they are not confident the COVID-19 vaccines available in the U.S. have been properly tested for safety and effectiveness. About 1 in 5 of each of these groups also say they will definitely not receive a COVID-19 vaccine.
• Access to a COVID-19 vaccine from an employer is a key aspect of vaccination rates among frontline health care workers. 6 in 10 health care workers who are not self-employed say they were either offered or received a COVID-19 vaccine from their employer (including 84% of vaccinated health care workers). Reflecting the overall vaccination rates among frontline health care workers, the share of workers who were offered a COVID-19 vaccine from their employer was much lower among those working in patients’ homes (34%).

The project, the 35th KFF/The Washington Post partnership survey, includes interviews with a nationally representative sample of 1,327 frontline health care workers (direct contact with patients and their bodily fluids), representing hospitals, doctors’ offices, outpatient clinics, nursing homes and assisted care facilities, and those working in home health care. The sample includes workers who work in many, and multiple, different aspects of patient care including patient diagnosis and treatment, administrative duties, and/or assisting with patient care such as bathing, eating, cleaning, exercising, and housekeeping. The survey also included a comparison survey allowing researchers to compare the group of frontline healthcare workers to the general population, that included 971 U.S. adults not working as frontline health care workers. The margin of sampling error for the group of frontline health care workers is 3 percentage points, national comparison sample is 4 percentage points. For results based on subgroups, the margin of sampling error may be higher.

The American Rescue Plan Act, the COVID-19 relief package that became law on March 11, 2021, contains a number of provisions designed to increase coverage, expand benefits, and adjust federal financing for state Medicaid programs. These provisions are briefly described below and summarized in Table 1. Separate briefs summarize provisions in the new law relating to the Marketplaces and public health.

Coverage provisions

The law provides an additional temporary fiscal incentive to encourage states that have not yet adopted the Affordable Care Act (ACA) Medicaid expansion to do so. In addition to the 90% federal matching funds available under the ACA for the expansion population, states also can receive a 5 percentage point increase in their regular federal matching rate for 2 years after expansion takes effect. The additional incentive applies whenever a state newly expands Medicaid and does not expire. The new incentive is available to the 12 states that have not yet adopted the expansion as well as Missouri and Oklahoma, which are expected to implement expansion in July 2021. The increase in the regular matching rate is estimated to more than offset the increased state costs of expansion in these states for the first two years.

States have a new option to extend Medicaid coverage for post-partum women from the current 60 days to a full year. States that elect this option must provide full state plan benefits throughout the enrollee’s pregnancy and post-partum period and cannot limit benefits to only those that are “pregnancy related.” The new option is available to states for 5 years, beginning April 1, 2022.

Benefit provisions

The new law clarifies that COVID-19 vaccines and administration are covered without cost-sharing for Medicaid enrollees and provides 100% federal matching funds for this coverage. CMS previously had interpreted the Families First Coronavirus Response Act (FFCRA) vaccine coverage requirement to exclude certain enrollees receiving limited benefit packages. The coverage provision applies to all enrollees, except those eligible only for Medicare cost-sharing assistance (partial duals) or COBRA premium assistance, from March 11, 2021 through the last day of the 1st calendar quarter that begins at least 1 year after the COVID-19 PHE ends. The financing provision applies from April 1, 2021 through the last day of the 1st quarter that begins at least 1 year after the PHE ends.

The new law adds coverage of COVID-19 treatment services, without cost-sharing, for enrollees in the COVID-19 uninsured testing group and enrollees who receive alternative benefit plans (ABPs). This coverage includes specialized equipment and preventive therapies and treatment (if otherwise covered under Medicaid) of a condition that may seriously complicate treatment of COVID-19 for those presumed to have or diagnosed with COVID-19. The COVID-19 uninsured testing group was created by the FFCRA and is available at state option, with 100% federal matching funds, during the PHE. The benefit package for this group previously was limited to COVID-19 testing and testing-related services. Enrollees receiving ABPs include the ACA expansion group and other enrollees at state option. ABPs allow states to provide a benefit package based on a private insurance plan instead of the traditional Medicaid state plan benefit package. COVID-19 treatment services are required in ABPs from March 11, 2021 through the last day of the 1st calendar quarter that begins at least 1 year after the PHE ends. States providing COVID-19 treatment services in ABPs would receive the 90% enhanced federal matching rate for expansion adults or their regular federal matching rate plus the additional 6.2 percentage points under the FFCRA (ranging from 56% to 85% across states) for other populations.

States can receive a 10 percentage point increase in federal matching funds for Medicaid home and community-based services (HCBS) from April 1, 2021 through March 30, 2022. The new funds must supplement, not supplant, the level of state HCBS spending as of April 1, 2021, and states must  implement or expand one or more activities to enhance HCBS. HCBS help seniors and people with disabilities live independently in the community by assisting with daily self-care and household activities.

States have a new option to provide community-based mobile crisis intervention services with 85% federal matching funds for the first 3 years. The additional funds must supplement, not supplant, the level of state spending for these services in the fiscal year before the 1st quarter that a state elects this option. Services must be otherwise covered by Medicaid and provided by a multidisciplinary team to enrollees experiencing a mental health or substance use disorder crisis outside a hospital or other facility setting. These services generally do not have to be offered statewide, do not have to be comparable for all enrollees, and can restrict enrollees’ free choice of provider. The new option is available to states for 5 years, beginning April 1, 2022. The law also authorizes $15 million for state planning grants, to be awarded by the HHS Secretary as soon as practicable. 

The new law provides $250 million for state strike teams to be deployed to Medicaid-certified nursing facilities with diagnosed or suspected cases of COVID-19 among residents or staff. The strike teams will assist with clinical care, infection control, or staffing during the PHE.

Other financing provisions

The new law contains some other provisions that affect Medicaid financing. It provides 100% federal matching funds for 2 years, beginning April 1, 2021, for services received through Urban Indian health care organizations and Native Hawaiian health systems. It also eliminates the cap on the amount of rebates that manufacturers pay to Medicaid in exchange for coverage of their FDA-approved drugs on December 31, 2023, resulting in federal savings of $14.5 billion. The law also requires the HHS Secretary to recalculate states’ annual disproportionate share hospital (DSH) allotments to ensure that these payments are equal to what they would have been without the 6.2 percentage point increase in federal matching funds provided under the FFCRA.

Finally, the new law provides $8.5 billion in FY 2021 for provider relief fund payments to rural Medicaid, CHIP, and Medicare providers. These funds are available to compensate for health care related expenses and lost revenues attributable to the pandemic for rural providers who diagnose, test, or care for individuals with possible or actual COVID-19.

Two new KFF women’s health briefs dive deeper into key women’s health issues on the federal policy agenda: Postpartum Medicaid coverage in the American Rescue Plan of 2021 and the Title X Family Planning regulations. The Biden Administration campaigned on reversing the Trump Administration’s Title X Family Planning program regulations and improving maternal health care.

Medicaid Postpartum Extension: The American Rescue Plan Act of 2021 provides states with a new option to extend Medicaid postpartum coverage for women who have a Medicaid funded delivery from 60 days to 12 months. The Postpartum Coverage Extension in the American Rescue Plan Act of 2021 provides a deeper look at what the Act does for postpartum eligibility expansion and when it can take effect. It also covers questions going forward like what states might take this option? What does this mean for non-expansion states?

Title X: President Biden has directed the Department of Health and Human Services (HHS) to review the Trump Administration Title X Family Planning program regulations that ban abortion referrals and co-located abortion services and is likely to issue new regulations. Over 150 members of Congress have asked that the Trump-era regulations be rescinded no later than March 29. The Potential Scenarios for Issuing New Title X Regulations issue brief examines two possible scenarios and timelines for issuing new Title X regulations and distributing program funding to those grantees and sites that may seek to return to the Title X network if the abortion referral restrictions are lifted

For additional information on the current status of the Title X program and postpartum Medicaid coverage and other developments in women’s health policy, visit www.kff.org/womens-health-policy.

Introduction

On January 28, 2021, President Biden issued a Memorandum on Protecting Women’s Health at Home and Abroad, directing Health and Human Services (HHS) to review the Title X Family Planning program regulations issued by the Trump Administration. These rules prohibited Title X grantees from participating in the program if they provide abortion referrals or abortion services in the same physical location as well as other requirements. The Biden Memorandum calls for HHS to “consider whether to suspend, revise or rescind, or publish for notice and comment proposed rules suspending, revising, or rescinding those regulations, consistent with applicable law, including the Administrative Procedure Act.” In the short term, the Biden Administration could suspend enforcement of the Trump Administration regulations in the same way that they recently did for public charge. While this approach would permit clinic sites supported by existing grantees to once again provide abortion counseling and referrals, new regulations would be needed to make federal support available to new or previous grantees.

This issue brief reviews the process and scenarios for timelines by which the Biden Administration could address the loss of clinics triggered by the Trump regulations by issuing new regulations and awarding new grants under the updated regulations. On March 8, 2021, 162 members of Congress sent a letter to the acting secretary of HHS urging the agency to swiftly complete their review of the Trump-era regulations and to rescind that rule no later than March 29, 2021.

Since it was first promulgated by the Trump administration on June 1, 2018, the regulation has been the focus of several lawsuits. Family planning clinics, providers, and 23 State Attorneys General have challenged the Trump Administration regulations on the grounds that they violate provisions of the Affordable Care Act (ACA), the Administrative Procedures Act and Section 1554 of the ACA. On February 22^nd, the Supreme Court announced it will hear the challenges. Assuming that the Biden Administration will not defend the Trump Administration regulations, a coalition of attorneys general from 19 states filed a motion to intervene  and separately the American Association of Pro-Life Obstetricians & Gynecologists, the Christian Medical and Dental Associations, and the Catholic Medical Association also filed a motion to intervene as a party to defend the Trump Administration regulations. On March 12, 2021, the plaintiffs, (including the AMA, Planned Parenthood, other family planning provider groups and attorneys general in 23 states) and the Solicitor General asked the Supreme Court to dismiss the cases. Even if the litigation over the Trump Administration regulation is ended, a final regulation that is in effect, can generally only be rescinded or altered by promulgating new regulations and we discuss two options and the timeline for doing so below.

Two Options for Promulgating New Regulations

There are two ways new regulations can be promulgated per the Administrative Procedures Act. One option is a Notice of Proposed Rule Making (NPRM). An NPRM is the standard process where the proposed rules are published in the Federal Register and then open for public comment for at least 60 days. The agency is then required to address the public comments and only then are regulations published in the Federal Register and considered final.

Another option is an interim final rule, which is published as a final rule and effective immediately but this approach provides an opportunity for the public to comment at the time the rule is published. An interim final rule is a faster process than an NPRM but can only be promulgated with “good cause” and when an agency decides it is “impracticable, unnecessary, or contrary to the public interest” to go through the longer process of proposed rulemaking.

Scenario One: Notice of proposed rule making (NPRM)

The Biden Administration could promulgate a new rule by following the process for issuing a notice of proposed rulemaking (NPRM) where the proposed rule is published in the Federal Register and then open for public comment for at least 60 days. HHS would then review the public comments, respond to them, make changes to the rule accordingly, and then publish final regulations. Regulations usually become effective 60 days after publication but the agency could make them effective sooner if it has good cause.

Under the fastest timeline, which would likely take at least five months to implement (Figure 1), the Biden Administration could publish a notice of proposed rulemaking in the federal register in March of 2021, followed by at least a 60-day public comment period. Over the next month, HHS would then review the public comments, prepare a response to them, and potentially issue a final rule as early as June 2021. At its fastest, the NPRM process would likely take at least five months, but it often can take longer. For example, the Trump Administration’s NPRM process for promulgating new Title X regulations took nine months from June 1, 2018 to March 4, 2019, and the first provisions became effective 60 days after publication on May 3, 2019.

Scenario TWO: ISsue an interim final rule

If the Biden Administration issues an interim final rule, the new regulations would become effective immediately. Because an interim final rule can only be promulgated if there is good cause to do so, however, HHS would need to determine that going through the longer process of proposed rulemaking is contrary to the public interest. The Biden Administration could cite the substantial decline in participating clinics and clients served by the program, as well as the six states that no longer have any Title X funded clinics (Figure 2). While an interim final rule might be the faster option, it increases the risk that organizational grantees and representatives of state interests that do not want to adhere to the new regulations would present a legal challenge on the grounds that they are held to follow a regulation that differs from the ones under which they applied.

New Funding Opportunity Announcement

Once there are new regulations, the grantees that disburse the Title X funds to the clinic sites that are still in the Title X program can change the requirements for program participation, requiring them to offer  pregnancy options counseling that includes abortion along with prenatal care and adoption, as well as abortion referrals and allow financial separation rather than full physical separation from onsite abortion services. They could also begin to bring clinics that left the program because they felt they could not adhere to the Trump Administration regulations back into their networks. However, in the states that no longer have Title X grantees or who have lost a large share of grantees (high need areas), the Office of Population Affairs (OPA) would need to issue a funding opportunity announcement (FOA) under the new regulations to resume federal support for services to these areas. If an interim final rule is issued shortly, a new FOA could be released as early as March 2021, or as late as June 2021 if the regulations are published through the slower NPRM process. Typically, grantees are given at least 60 days to prepare and submit applications, followed by an OPA review which could take between 30 and 60 days, and OPA could therefore grant awards as early as June/July 2021 with an interim final rule or September/October 2021 with an NPRM. The new American Rescue Plan Act of 2021 included a $50 million dollar supplemental appropriation to the Title X Family Planning Program to make grants and contracts, which could be used to bring Title X grantees that have left the program back into the program through this new FOA and still keep funding levels stable for those who stayed on.

In addition to bringing grantees of high need areas back into the Title X program, OPA will also have to issue a funding opportunity announcement for renewal of all the current grantees whose three-year grant cycle ends March 31, 2022. If the agency keeps with previous funding cycles, OPA will likely release an FOA for the existing grantees this October or November. Those grantees would be given at least 60 days to respond to the FOA with applications due in January 2022 and new awards by April 1, 2022 when the funding cycle ends. It is possible that OPA would have to go through the funding opportunity cycle twice in the span of a few months to fund new/returning grantees who have been disqualified under the Trump Administration rules as well as those that have stayed in the program.

Will There Be New Legal Challenges to Biden Administration’s Title X Regulations?

No matter how the Biden Administration implements new Title X regulations, there may be legal challenges. A coalition of 19 states have filed a motion to intervene in the cases currently at the Supreme Court claiming an interest because some have received additional funds under the Trump Administration regulations and the rules “eliminated any confusion about the States’ involvement in the provision of abortion.” If the Supreme Court dismisses the cases as requested by the parties in the case, these states may challenge the Biden Administration regulations. Religiously affiliated organizations that became grantees under the Trump Administration regulations may also challenge the Biden Administration regulations, claiming that they should qualify for a grant even if they are religiously opposed to the provision of pregnancy options counseling which includes the options of abortion and referrals to abortion services when requested.

The Trump Administration sought to expand the Title X network to include new “family planning” grantees who offer fertility awareness-based methods and prioritize abstinence, but not necessarily offer contraception to their clients. Obria Medical Group, a Catholic organization that has religious objections to contraception and abortion, applied for a Title X grant in January 2019 and was awarded a grant of over $5 million over 3 years. Obria views their services “as a form of Christian Ministry which must conform to the tenets of that faith in its treatment of the vulnerable… and that to refer for or otherwise facilitate an abortion is gravely sinful.”

When Obria applied for the Title X grant in January 2019, they assumed that the Trump Administration’s final rule would be in effect during the grant period. However, the Trump Administration final rule was initially blocked by federal courts and the prior regulations (which were in place until July 15, 2019), required nondirective pregnancy options counseling and abortion referrals.

In May 2019, Obria filed a lawsuit against HHS, requesting an injunction to stop enforcement of the requirement to provide nondirective pregnancy options counseling and abortion referrals, claiming this requirement violates their religious rights. The following month, they withdrew their lawsuit, after Health and Human Services sent them a letter effectively notifying them that they would not be required to provide abortion referrals if they have a religious objection and would still be eligible for federal Title X support.

The Biden Administration will likely have a different interpretation of the Title X statute and will require all grantees to comply with all the rules of the Title X program (including non-directive pregnancy options counseling, contraception, and abortion referral) which would effectively disqualify Obria from continued participation in the program. Therefore, Obria may file a legal challenge to regulations if they are disqualified from receiving Title X funds, and the courts will be asked to answer the legal question: Is the federal government required to provide a federal grant to an organization that has religious objections to fulfilling the requirements of the grant?

Look Forward

The federal rule-making process is not fast, nor is the funding opportunity and application process. Today, the Title X program is serving far fewer clients than before the Trump regulations took effect and there are many parts of the country that no longer have clinics that are receiving federal support. By issuing the Memorandum on Protecting Women’s Health at Home and Abroad in his first eight days of his presidency, President Biden signaled that this is a top priority for his administration, but the process for implementing new regulations and distributing new funding will take time.

Inside the $1.9 trillion American Rescue Plan Act of 2021 is a less noticed provision that makes a major change to Medicaid coverage for low-income pregnant and postpartum women, addressing a long-standing gap for people who have had their maternity care covered by Medicaid, especially those in states that have not expanded Medicaid as permitted by the ACA. While the Act adds new incentives for states to take up the ACA Medicaid expansion, it also now gives all states the new option to extend the postpartum coverage period under Medicaid from 60 days following pregnancy to a full year. This post explains the new policy and raises some questions that policymakers are likely to grapple with as the implementation unfolds.

What does the new policy do?

• The American Rescue Plan Act of 2021 gives states a new option to extend Medicaid postpartum coverage from 60 days to 12 months. Currently, Medicaid covers almost half of births nationally, with eligibility levels ranging from 138% to 380% of poverty across states. States must cover pregnant women with incomes up to 138% of the federal poverty level (FPL) through 60 days postpartum (the end of the month of the 60^th postpartum day). The American Rescue Plan Act allows states to extend the postpartum period to a year by filing a State Plan Amendment (SPA) to their Medicaid program.
• Under the new law, the postpartum coverage duration can also be lengthened under the CHIP program. Currently, six states cover some low-income pregnant women through their CHIP programs. If a state takes up the new option to extend the postpartum period, this will apply to their CHIP coverage in addition to Medicaid.
• States that elect the new option must provide full Medicaid benefits during pregnancy and the extended postpartum period. Currently, states are permitted to cover a more narrow set of pregnancy-related benefits to those who qualify under the pregnancy pathway, although most align their benefits with other Medicaid eligibility groups. States that elect this new option however would have to provide full Medicaid benefits.
• The new option can take effect starting April 1, 2022 and would be available to states for five years. While the new option takes effect next year, currently postpartum women covered by Medicaid can remain on the program beyond 60 days because of a Maintenance of Effort requirement enacted in 2020 that lasts through the COVID public health emergency.

Questions going forward

• Which states will take up this option? While we do not know which states will take up the option, several have shown interest in extending the postpartum coverage period beyond 60 days. Some states have applied and have waivers pending at CMS to extend postpartum coverage. This includes expansion states like Illinois and New Jersey as well as non-expansion states like Georgia (which applied for extension through 180 days postpartum). These states could now file a SPA instead of waiting for approval of their waivers. Some states may decide to change earlier proposals. For example, Missouri has submitted a waiver application to CMS that would extend postpartum coverage to a year just for substance use and mental health services. That proposal would not qualify for the new SPA option because it would not cover full benefits.
• What will be the impact on women’s coverage in non-expansion states? Non-expansion states that take up the option could see a decrease in the share of low-income mothers who are uninsured. Medicaid income eligibility levels for parents are much lower than for pregnant people (Figure 1). Currently, in non-expansion states, some new mothers fall into the coverage gap where their incomes are too high for Medicaid parent eligibility yet too low for Marketplace subsidies (which are available only at the poverty level or above), putting them at risk for becoming uninsured.

• Will this option be adopted by expansion states? In states that have expanded Medicaid under the ACA, most postpartum women have a pathway to coverage – either Medicaid or subsidized private insurance through the ACA Marketplaces, but a longer postpartum period could allow for greater continuity with Medicaid providers. Studies have documented that new moms who have Medicaid funded childbirths experiencing significant churning in coverage.
• What will be the impact on federal and state budgets? The Congressional Budget Office (CBO) estimates that by 2024, about a quarter of postpartum beneficiaries will live in states that elect the new option. CBO estimates that extended Medicaid coverage will result in almost $6.1 billion in federal spending over the first ten years. States that adopt this extension would also incur costs as the extended coverage would remain at the same federal matching level, which ranges from 56.2% to 84.51%. These estimates take into account potential shifts in private insurance enrollment, including lower ACA subsidy costs. It is not clear if the estimates account for factors such as greater access to preventive services like contraception, which could avert unintended pregnancies that would otherwise be covered by Medicaid.
• What will be the impact on health outcomes? Part of the motivation for postpartum extension is the nation’s high rate of preventable pregnancy-related mortality and morbidity, particularly the stark disparities among Black and Native American women. There is also growing recognition that the postpartum period extends far beyond 60 days. Many of the conditions that account for a significant share of pregnancy-related mortality and morbidity, such as cardiovascular diseases, hypertension, and depression often require care over a longer-term. Providing Medicaid access to low-income mothers for a longer period also promotes continuity and access to preventive services such as contraception and intrapartum care.–The role of coverage as a key element of reproductive health care access is well understood. However, maternal health is also heavily connected to a complex set of issues, particularly poverty and systemic racism that pervade the health care system.

Ensuring widespread global access to COVID-19 vaccines, which is necessary for preventing cases and deaths and contributing to global population immunity, is a critical challenge and one that could threaten the ability to control the pandemic. Despite efforts to address vaccine access, most notably through the creation of COVAX, which aims to support the development and delivery of COVID-19 vaccines with a particular focus on assisting low- and middle-income countries, significant disparities remain. The latest data from the Duke Global Health Innovation Center Launch and Scale Speedometer, which monitors COVID-19 vaccine purchases, finds that high-income countries already own more than half of all global doses purchased, and it is estimated that there will not be enough vaccine doses to cover the world’s population until at least 2023.

To further examine the current global distribution of COVID-19 vaccine doses, we used data from the Duke Launch and Scale Speedometer to calculate the share of doses purchased by country income group compared to their share of the global adult population (focusing on adults, ages 18+, because most COVID-19 vaccines are thus far only available for the adult population). In addition, we calculated potential vaccine coverage rates – that is, the share of the adult population that could be fully vaccinated – by country income group. To do so, we reapportioned doses secured through regional agreements to their respective country recipients and added these to individual country totals where bilateral agreements were also in place. While it is not possible to allocate most COVAX doses purchased to individual countries at this time, since COVAX has yet to release its full distribution plan, we did assess how allocating  all COVAX doses to low- and middle-income countries (LMICs) would affect these distributions (see Methodology for more detail). Ultimately, we find that without redistribution of doses already purchased by high-income countries (through donations or other means) and/or increased support for manufacturing or production of additional doses, more than four in ten (41%) adults in the world will not be able to be vaccinated, even after allocating all COVAX doses to LMICs.

High-income countries, representing just a fifth of the global adult population, have purchased more than half of all vaccine doses, resulting in disparities between adult population share and doses purchased for all other country income groups. We find that although high-income countries only account for 19% of the global adult population, collectively, they have purchased more than half (54%, or 4.6 billion) of global vaccine doses purchased to date. Of the remaining doses, 33% have been purchased by LMICs, who account for 81% of the global adult population; an additional 13% have been purchased by COVAX. Looking by country income group, the largest disparity between doses purchased and population share is for lower-middle-income countries (37% of the global population vs. 12% of purchased doses, or 989 million doses), followed closely by upper-middle-income countries (37% vs. 18%, or 1.5 billion doses). The disparity for low-income countries is smaller (3% vs. 7%, or 263 million doses) (see Figure 1a).

The disparity is even more pronounced when looking at the share who could be vaccinated. While enough vaccine doses have been purchased to cover more than 80% of the adult population, high-income countries own enough doses to vaccinate more than twice their populations while LMICs can only cover one-third.

High-income countries currently have enough vaccine doses to cover more than twice their adult populations (245% see Figure 2a). Meanwhile, LMICs currently only have enough vaccine doses to reach approximately one-third of their populations, with upper-middle-income countries able to cover 39% of their adult population, low-income countries 38%, and lower-middle-income countries 27%.

Providing all COVAX doses to LMICs could help but would still leave vaccines out of reach for most of the global population. COVAX, which currently accounts for 13% (1.12 billion) of the total number of global doses purchased, has not yet finalized the distribution plan for its full supply, though most doses are expected to be distributed to LMICs. We looked at what would happen to global distribution, relative to population and to vaccine coverage, if all 1.12 billion COVAX doses were provided to LMICs (which is not going to be the case since some will go to high-income countries). While this would result in the share of doses purchased for LMICs increasing from 33% to 46%, it would still be well below their share of the global adult population (81%) (see Figure 1b). Moreover, even with the COVAX doses, less than half (49%) of the adult population in LMICs would be able to be vaccinated (see Figure 2b). Looking at potential global coverage rates, allocating all COVAX doses to LMICs only slightly improves the picture, increasing the percentage of adults globally that can be vaccinated from 46% to 59%. This is well below the percentage of adults globally that could be vaccinated based on the total number of doses purchased (86%) (see Figure 3).

The disparity between vaccines purchased and country income level is significant, but could be addressed in large part through redistribution of doses, as some high-income countries have said they would do. However, such a strategy is highly dependent on the as-of-yet unknown outcomes of several vaccine candidate trials or a significant increase in the manufacturing and production of already authorized vaccines. This analysis demonstrates the significant disparity in vaccine access across much of the world, at least of doses purchased to date. While high-income countries have secured enough doses for more than twice their adult population, LMICs currently have only enough doses to vaccinate just a third, or, if all COVAX doses were allocated to them, still less than a half. Although there are currently enough purchased doses to vaccinate more than 80% of the global adult population, unless these doses are redistributed, huge inequities in vaccine distribution will persist, presenting a major challenge to achieving global population immunity. Some high-income countries have indicated that they will donate their excess doses, including France, Norway, the U.K., and the U.S. government, which has said it will do so only after it has vaccinated the U.S. population. Still, even if such donations were to occur, their ability to fully address these disparities is in part dependent on the success of some vaccine candidates still in clinical trials or the ability to support the increased manufacturing of or production capacity for already successful vaccine products.

The American Rescue Plan (ARP), recently signed into law by President Biden, increases and expands eligibility for Affordable Care Act (ACA) premium subsidies for people enrolled in marketplace health plans. The law also creates new, temporary premium subsidies for COBRA continuation coverage; and it temporarily changes the rules for year-end tax reconciliation of marketplace premium subsidies. These changes will improve the affordability of coverage for individuals who are already enrolled in marketplace health plans, and will provide millions more an opportunity to newly sign up for coverage with increased financial assistance this year.  The law also made changes to the Medicaid program designed to increase coverage, expand benefits, and adjust federal financing.

Expanded Marketplace Premium Subsidies

Under ARP, ACA marketplace premium subsidies are substantially enhanced for people at every income level and, for the first time, offered to those with income above 4 times the federal poverty level (FPL).

People up to 150% FPL can now get silver plans for zero premium with vastly reduced deductibles. Previously, marketplace premium subsidies were partial; no matter how poor, people had to contribute something toward the cost of the benchmark silver plan (i.e., the second lowest cost silver plan in their area).  Those with income at 100% FPL had to contribute 2.07% of household income ($264 per year in 2021) toward a benchmark plan; at 150% FPL that amount increased to 4.14%  of household income( $792 per year).  Now under ARP, the benchmark marketplace plan will be fully subsidized for people earning up to 150% FPL.  Cost sharing subsidies were already most generous at this income level (the average silver plan deductible for people at 150% FPL is $177 this year). As a result, low income people now can qualify for premium-free silver plans with modest deductibles for covered health benefits.

Premium subsidies will also increase for people at higher income levels among those currently eligible for help with incomes up to 400% of the poverty level. Premium tax credits will increase for people at every income level. (Figure 1) People with income of 200% FPL had been required to contribute $1,664 toward the cost of the benchmark marketplace plan this year; now under the ARP they will have to contribute just $510. At income of 400% FPL, people were required to contribute up to $5,017 toward the benchmark plan premium, now they will be required to contribute no more than $4,338 toward that plan.

People with income above 400% FPL will be newly eligible for marketplace premium subsidies. Under the ACA, people with income above 400% FPL were not eligible for marketplace premium subsidies. Now, they will be required to contribute no more than 8.5% of household income toward the benchmark plan. This change will provide limited relief to younger marketplace participants – for example, for 24-year-olds in most areas, the unsubsidized age-rated benchmark plan premium already costs less than 8.5% of income for someone at 401% FPL – but will offer substantial relief for older individuals, where the unsubsidized premium averages nearly 25% of household income for someone at that same income level who is 64 years old. (Figure 2) Before this change, when they were ineligible for premium subsidies, some people with income above 400% FPL bought their insurance outside of the marketplace, or bought non-ACA compliant plans (such as short term policies). These individuals may want to return to the marketplace where coverage may now be more affordable and more comprehensive. The Biden Administration has reopened marketplace enrollment through May 15.

The ARP premium subsidy enhancements are effective during 2021 and 2022. These changes to marketplace premium subsidies are temporary, in effect only during calendar years 2021 and 2022. The specifics and timeline for implementation of these changes is yet to be determined. However, once implemented, current enrollees may be able to sign into their marketplace account to increase the amount of advanced premium tax credit (APTC) they receive, thereby lowering their monthly health plan premium payment for the remainder of this year. Subsidies for current enrollees are retroactive to the beginning of this calendar year and can also be claimed as tax refunds when people file their 2021 tax return next year.

In HealthCare.gov states, current enrollees will also be able to change plans during the COVID enrollment period, which currently extends through May 15, 2021. People covered in state-based marketplaces should check with their marketplace for information about their ability to change plans as the new premium subsidies are implemented. Presently, some state-based marketplaces offer a COVID enrollment period when only uninsured individuals can sign up.

Enhanced Subsidies for Unemployed People

The ARP provides for enhanced marketplace subsidies for people who receive or are approved to receive unemployment insurance (UI) benefits during any week in 2021. The ARP also extends the current federal supplement ($300 per week) to state UI benefits through September 6, 2021. The federal UI supplement is not taken into account in determining eligibility for Medicaid or CHIP.

When UI recipients apply for marketplace subsidies, special rules will be in effect during 2021.

Household income in excess of 133% FPL will be disregarded for purposes of determining eligibility for marketplace premium and cost sharing subsidies in 2021. As a result, people who receive UI benefits at any time in 2021 will be eligible for a zero-premium benchmark silver plan with comprehensive cost sharing subsidies this year.

People receiving UI benefits will be considered “applicable taxpayers” during 2021. Normally under the ACA, to be eligible for marketplace subsidies, a person must qualify to be an “applicable taxpayer” which requires having an income of at least 100% FPL. Under the ARP, for 2021 only, people who receive UI benefits are defined to be an applicable taxpayer. That can help some UI recipients with income below the federal poverty level who live in states that have not adopted the ACA Medicaid expansion; they were otherwise in the “coverage gap,” ineligible for both Medicaid and marketplace subsidies.

These enhanced marketplace subsidies for UI recipients are only for the 2021 coverage year.Congress would need to enact further legislation to extend UI subsidy enhancements beyond this year.

People receiving UI benefits will still have to meet other requirements to be eligible for marketplace subsidies. In particular, married individuals must file a joint return to be eligible for subsidies. Using the married-filing-separately filing status generally makes a person ineligible for subsidies, though an exception is available for people who experience domestic abuse.

In addition, people receiving UI benefits may still be ineligible for marketplace subsidies if they have access to job-based health benefits that meet ACA standards for affordability and minimum value. The affordability of job-based coverage will continue to be measured based on household income, including UI benefits and amounts above 133% FPL.

Premium Tax Credit Repayment Holiday for 2020

When people apply for marketplace premium subsidies, they do so based on their estimated annual income for that tax year. Later, when they file federal tax returns for that year, people must reconcile their actual income with the amount of premium tax credit they received based on estimated income, and repay some or all of any excess premium tax credit (or receive an additional credit if actual income was lower than anticipated). Caps on the repayment amount apply, but if actual income exceeds 400% FPL, people must repay the entire amount of excess premium tax credit they received during the year.

Recognizing that the pandemic caused greater-than-usual economic disruption and uncertainty in 2020, the ARP waives repayment of any excess premium tax credit received by marketplace participants during that year.

Implementation questions remain to be addressed. Before the ARP was enacted, the Internal Revenue Service (IRS) had already finalized 2020 tax forms and schedules, which provide for APTC reconciliation and repayment of excess credits. Further action by the IRS will likely be forthcoming to educate the public about this new protection, advise on how to use it when filing the 2020 tax return, and to refund amounts to people who may have already filed their 2020 tax return with repayments.

Temporary COBRA Premium Subsidies for 2021

The ARP provides for temporary COBRA premium subsidies for up to 6 months during 2021. Subsidies will cover 100% of the monthly cost of COBRA while people are eligible. The law requires the former employer to pay the COBRA premium for subsidy-eligible individuals; the federal government will then reimburse the former employer for this cost.

The COBRA premium subsidies can be paid for coverage months no earlier than April 1, 2021 and no later than September 30, 2021. The subsidy can end earlier than September 30 in some circumstances.  It ends when COBRA coverage is exhausted; so for example, someone who first became eligible for COBRA due to a job layoff on March 1, 2020 could continue in that plan for 18 months, or through August 2021.  That person could claim the COBRA premium subsidy starting in April 2021, but the subsidy would stop when COBRA exhausts at the end of August.  People also lose eligibility for the COBRA premium subsidy once they become eligible for other job-based coverage.  If this happens, people must notify their COBRA plan administrator or risk owing a penalty.   

The subsidy is for people whose COBRA qualifying event involves termination of employment or reduction in hours worked. People are not eligible for the COBRA subsidy if they quit voluntarily. Nor are they eligible for subsidies if COBRA resulted from other qualifying events, including death of or divorce from the covered employee, the covered employee becoming entitled to Medicare, or loss of dependent child status.

People who became eligible for COBRA earlier in the pandemic can still elect it. Normally, people have up to 60 days from their qualifying event to elect COBRA continuation coverage. During the pandemic, however, people have additional time to elect COBRA, thanks to a COVID disaster relief notice issued by the Departments of Labor and Treasury. Their new COBRA election deadline will be the earlier of (1) one year from the date the person’s election period would otherwise have ended, or (2) 60 days after the announced end of the COVID National Emergency. For example, a person who was laid off early in 2020 and whose deadline for electing COBRA was April 1, 2020 can now take until April 1, 2021 to elect COBRA. Going forward, a person who becomes newly eligible for COBRA can have her election period extended by up to 1 year (or until 60 days following the end of the National Emergency, whichever is earlier.) This emergency rule applies to election of COBRA arising from all qualifying events.

People who became eligible for COBRA earlier in the pandemic can have coverage start prospectively. Normally, once elected, COBRA coverage dates back to the qualifying event and premiums have to be paid retroactive to that point in time. This will remain the rule for subsidy-eligible people whose qualifying event occurs on or after April 1, 2021

However, under the ARP a special rule applies for subsidy-eligible individuals whose COBRA qualifying event pre-dates enactment of the ARP and who have not yet elected COBRA; or for such individuals if they previously elected COBRA but subsequently discontinued it, and who otherwise remain eligible for COBRA. When these individuals elect COBRA, coverage will commence on the first day of April 2021. Their COBRA coverage will not extend back in time before that date and they will not owe COBRA premiums prior to that date.

Eligible individuals who were already paying for COBRA when the law passed can also claim the subsidy.

COBRA premium subsidies are not counted as income to the individual. Subsidies will not affect a person’s tax liability or eligibility for other income-related benefits.

People eligible for COBRA subsidies may also be eligible for marketplace subsidies or Medicaid. Just being eligible for COBRA does not affect a person’s eligibility for marketplace subsidies or Medicaid. Those who have a choice will want to weigh their out of pocket costs (for premiums and cost sharing, net of subsidies), as well as any differences in plan provider networks, covered benefits, and other plan features. Generally, once a person enrolls in COBRA, she won’t have an opportunity to choose marketplace coverage again until the earlier of the next open enrollment period or the date when she exhausts COBRA coverage.

When COBRA premium subsidies end, people can continue unsubsidized enrollment in COBRA. Of course, for many, unsubsidized COBRA may prove unaffordable. Generally, if a person terminates (or stops paying the premium for) COBRA before it exhausts, this loss of coverage does not make a person eligible for a special enrollment period (SEP) in the marketplace.

However, the marketplace has broad authority to recognize new SEP qualifying events. It remains to be seen if HealthCare.gov and state-based marketplaces will recognize termination of COBRA premium subsidies as a qualifying event and allow people the option to switch to more affordable marketplace plans and subsidies at that time.

Other ARP Changes and Affordability

Stimulus payments – The ARP provides for stimulus payments up to $1,400 for qualifying individuals in 2021. These payments are considered tax credits and are not counted as income for purposes of tax liability or eligibility for income-based programs and benefits.

Exemption of UI benefits from federal income tax in 2020 – The ARP also included a provision exempting the first $10,200 in UI benefits paid to an individual in 2020 from inclusion in that individual’s adjusted gross income for that year, which will also lower countable income for the purposes of marketplace premium subsidies. As a result of this change, people who participated in the marketplace in 2020 may find they were eligible for greater premium tax credits than they claimed during the year. If so, people can receive unclaimed 2020 APTC as a refundable tax credit when they file their 2020 federal income tax return. People who already filed their 2020 return before the law was enacted should be able to claim the refund, as well.

Next steps?

These significant changes to make private coverage more affordable were enacted after many people had already enrolled in 2021 marketplace plans, after HealthCare.gov and state-based marketplaces had announced a time-limited special COVID enrollment opportunity, and after the 2020 tax filing season was underway. It will take time for federal and state agencies to implement these changes, including updates to marketplace subsidy eligibility systems, drafting of model notices, and revision of tax forms. The Department of Health and Human Services has announced that the enhanced ACA premium subsidies will be available through HealthCare.gov beginning April 1, but other changes in the ARP may take more time. Under the current special COVID enrollment period, people will have until May 15 to newly sign up for coverage or change plans to take advantage of the additional help.

On March 11, 2021, President Biden signed the American Rescue Plan Act of 2021 (P.L. 117-2), a $1.9 trillion stimulus package, into law.  Among other things, this latest relief bill, the nation’s sixth, infuses new funding for critical COVID-19 public health activities, including vaccine distribution, testing, contact tracing, surveillance, and the public health workforce, building on prior emergency relief funding provided by Congress (other provisions of the bill expand the Affordable Care Act by making marketplace and private health insurance more affordable and by providing new incentives to states that have not yet expanded their Medicaid programs to do so). Funding for COVID-19 public health focused activities in the bill totals almost $93 billion, most of which has been made available until expended. The main public health provisions are as follows:

• $7.5 billion (Section 2301) to the Secretary of Health and Human Services (HHS) to provide to the Centers for Disease Control and Prevention (CDC) for COVID–19 vaccine distribution and administration, including support for State, local, Tribal, and territorial public health departments. Activities include the establishment and expansion of community vaccination centers and mobile vaccination units, particularly in underserved areas; reporting enhancements; communication efforts; and transportation of individuals to vaccination, particularly underserved populations.
• $1 billion (Section 2302) to HHS to provide to CDC for vaccine confidence, information, and education activities.
• $6.05 billion (Section 2303) to HHS to support the supply chain for COVID-19 vaccines, therapeutics, and ancillary medical products through research, development, manufacturing, production, and purchasing
• $500 million (Section 2304) to the Food and Drug Administration (FDA) for activities related to COVID-19 vaccines, therapeutics, and diagnostics, including for evaluation of their continued performance, safety, and effectiveness and facilitation of advanced continuous manufacturing.
• $47.8 billion (Section 2401) to HHS for testing, contact tracing, surveillance, and mitigation activities, including for the development of a national evidence-based strategy, support for State, local, and territorial public health departments, support for development, manufacturing, procurement, distribution, and administration of tests, and to establish and expand Federal, State, local, and territorial testing and contact tracing capabilities.
• $1.75 billion (Section 2402) to HHS to be provided to CDC for SARS-CoV-2 genomic sequencing and surveillance, including support for State, local, Tribal, or territorial public health departments or public health laboratories.
• $500 million (Section 2404) to CDC for data modernization and forecasting.
• $7.66 billion (Section 2501) to HHS for the public health workforce, including support for State, local, and territorial public health departments to hire case investigators, contact tracers, social support specialists, community health workers, public health nurses, disease intervention specialists, epidemiologists, program managers, laboratory personnel, informaticians, communication and policy experts, and any other positions as may be required to prevent, prepare for, and respond to COVID–19 and to provide PPE.
• $100 million (Section 2502) to HHS for the medical reserve corps.
• $7.6 billion (Section 2601) to HHS for community health centers for activities including COVID-19 vaccine distribution and administration, testing, contact tracing, mitigation, workforce enhancement, and community outreach and education.
• $10 billion (Section 3101) to enhance use of the Defense Production Act for the purchase, production, or distribution of medical supplies and equipment for COVID-19 including for testing, PPE, vaccines and other drugs and biological products.
• $2.34 billion (Section 11001) to the Indian Health Service for COVID-19 vaccine distribution and administration ($600 million); testing, contact tracing and mitigation ($1.5 billion); and public health workforce for COVID-19 ($240 million).