Key Takeaways

• One in ten women report quitting a job due to a pandemic related reason and almost half said that one of the reasons was because they felt unsafe at their workplace.
• School closures had a substantial effect on working mothers’ ability to fulfill work obligations. One in ten working mothers with children under 18 said they quit a job due to COVID and half of this group cited school closures as one of the reasons. Three out of ten working mothers said they had to take time off because school or daycare was closed.
• In addition to juggling new, increased home and work responsibilities, many women went without pay due to school closures. Almost half (47%) of working mothers said they took unpaid sick leave because their child’s school or daycare was closed. This rose to 65% among low-income mothers and 70% among those working part-time jobs.
• Family caregiving responsibilities before and after the pandemic have largely fallen on women. More than one in ten women report they were caring for a family member who needed special assistance prior to the pandemic. Over one in ten women report that they have new caregiving responsibilities as a result of the pandemic.
• Over half of mothers with school age children said that the stress and worry of the pandemic has affected their mental health, with one in five characterizing the impact as “major.” However, only 16% of mothers have sought mental health care. Given that the mental health effects are likely to persist for a long time, access to mental health care will be an important issue to watch, particularly for mothers.

Introduction

While the COVID-19 pandemic has impacted people across the US, changing the way we work, live, and access health care, gender-based disparities that existed prior to the pandemic have been magnified. Many women have been on the front lines of the COVID-19 emergency, as essential workers, mothers, and caregivers. Lack of paid leave, family caregiving responsibilities, traditional gender roles, and health concerns have placed many of the burdens of the pandemic squarely on the shoulders of women, falling particularly hard on women of color and those who are low-income. This brief provides new data from the KFF Women’s Health Survey, a nationally representative survey of 3,661 women and 1,144 men ages 18-64 (Methodology) conducted November 19, 2020 – December 17, 2020. Among several topics related to women’s health and well-being, we asked respondents about experiences during the COVID-19 pandemic. In this brief, we highlight how experiences during the COVID-19 pandemic related to work, childcare, and caregiving differ by gender and among different subpopulations of women.Nearly 1 in 10 women (8%) report quitting their job for a reason related to COVID-19. Larger shares are younger, Black or Hispanic,¹  uninsured, low-income, and have less than a Bachelor’s degree (Figure 1). For example, 17% of low-income women had to quit a job for a COVID-related reason, compared to 5% with higher incomes.

Almost half of women who have quit a job for a reason related to COVID-19 (48%) say they quit because they did not feel safe at their workplace. Three in ten women (30%) quit their job due to COVID-19 because their child’s school or daycare was closed (Figure 2). A larger share of women with Medicaid compared to women with private insurance (44% vs. 20%) and a larger share of low-income women compared to women with incomes ≥ 200% of the federal poverty level (FPL)²  (37% vs. 23%) say they had to quit their job because their child’s school or daycare was closed, leaving the most disadvantaged with a loss of income. Nearly a quarter of women say they quit a job because they live with someone at elevated risk for COVID-19 complications.

Half of mothers who quit a job because of the pandemic said one of the reasons was because their child’s school or daycare was closed. With in-person schools closed, mothers have taken on many new responsibilities, including even more childcare than usual, assisting with remote learning, and in some cases shifting to full homeschooling just to name a few. For mothers of young children who also work outside the home, they have been doing all of this while trying to maintain employment. While most mothers have been able to maintain their jobs, some with changes to their workload and schedules, it is not surprising that some have had to leave jobs as a result of school and daycare closures and the numerous new responsibilities that mothers now carry. One in ten women with young children (11%) say they quit a job due to the pandemic (Figure 3). Among this group, half (51%) said one of the reasons was because their child’s school or daycare was closed. Many mothers (42%) also said they quit because they did not feel safe at their workplace (Figure 4).

The share of women who report leaving a job is significantly higher among single mothers (17%) compared to those who are married or have partners (9%). Single mothers may face the double jeopardy of not having a partner to assist with childcare or another source of income, however. Almost one in five mothers who are not currently working (18%) report that they had to quit a job due to the pandemic, as do 7% of working mothers, suggesting that some mothers who had to quit a job during the pandemic have since found another one.

Mothers were more likely than fathers to miss work due to school and daycare closures. Many workers had to take time off due to the COVID pandemic, due to illness as well as school and daycare closures. The largest difference between women and men having to take time off work was because of school or daycare closure due to COVID-19 – this burden fell largely on women with school age children (30% vs. 20%) (Table 1). Low-income women were disproportionately affected, with almost four in ten (38%) taking time off because their child’s school or daycare was closed compared to 27% of women with incomes ≥200% FPL. Rates were similar among mothers of different racial and ethnic groups, except for Asian women, who were less likely to have taken time off because of school and daycare.

In addition to bearing the brunt of childcare and caregiving responsibilities, many women lost pay during the pandemic because they missed work due to quarantining or school closures. Over one-third of women (35%) say they took unpaid sick leave when they became ill with COVID-19 or were quarantining, and nearly half of women (46%) say they took unpaid sick leave when their child’s school or daycare was closed due to COVID-19 (Figure 5). Most employers offer some amount of paid sick leave and the federal government provided support for emergency paid sick leave to some employers in 2020, but these benefits were not available to all workers and are time limited. Many women may not have been eligible for paid sick leave or may have taken more time off than available for pay at their workplace.

Over two-thirds of working mothers who were low-income and nearly three in four working part-time jobs were not paid when they had to take time off because their child’s school or daycare was closed due to the pandemic. Lack of a national paid leave policy disproportionately affects women, who are more likely than men to have to take time off work for childcare reasons, and some women are particularly affected. Part-time and low-wage jobs are less likely to offer paid leave benefits, as reflected in our survey. Most women in these jobs went without pay when they took time off due to school and daycare closures last year (Figure 6).

Nearly half of employed women have worked outside their home during the pandemic. More than half of men (53%) and nearly half of women (46%) report that they are working in a location outside their home during the pandemic. At the outset of the pandemic, some companies shifted to telecommuting, but many workers do not have this option as some industries and jobs are not amenable to remote work. Working outside of the home during the pandemic is more common among women who are younger, have lower educational attainment, live in rural areas, and report lower incomes. For example, more than half of Hispanic women (53%) compared to 45% of White women, have worked outside their home. Conversely, half of Asian women workers (51%) say they are working from home (Figure 7). More than half of women residing in rural areas (58%) report working outside the home, compared to 44% of women in urban communities.

Family caregiving responsibilities before and after the pandemic have largely fallen on women. More than one in ten women report they were caring for a family member who needed special assistance prior to the pandemic. Over one in ten women report that they have new caregiving responsibilities as a result of the pandemic. A higher share of women (14%) than men (9%) say they were caring for a family member who needed special assistance prior to the pandemic. This gender difference in caregiving extends to new caregiving responsibilities due to reasons related to the pandemic (12% of women vs. 8% of men) (Table 2).

One in five women ages 50-64 say they were caring for a family member who needs special assistance prior to the pandemic, higher than women in their reproductive years (11%), but similar shares (12%) in both age groups report taking on new caregiving responsibilities as a result of the pandemic.

Women who are parents of a child younger than age 18 in their household are significantly more likely than women without children under 18 to have taken on new or additional responsibilities caring for a family member because of the pandemic (16% vs. 10%). The pattern is similar among men, with 15% of men with children under age 18 reporting they have taken on new caregiving due to the pandemic, compared to 5% of men without children. However, it is worth noting that some respondents, especially parents of young children, may have interpreted new and additional responsibilities caring for a family member or relative as homeschooling. Almost one in five low-income women (19%) were caregivers before the pandemic compared to 13% of higher-income women. Low-income women (15%) are also more likely than higher-income women (11%) to have gained new caregiving responsibilities as a result of the pandemic.

Family caregiving falls heavily on some women of color too. Almost one in five Black women (18%) report caring for someone who needed special assistance prior to the pandemic, significantly higher than the 12% of White women. Eighteen percent of Hispanic women say they have had to take on new caregiving responsibilities since the pandemic started. Nearly one in ten Hispanic women workers (9%) say they have had to take time off work because they were caring for a family member quarantining from or sick with COVID-19.

For some caregivers, the pandemic compounded existing responsibilities. Among women and men who were already caring for someone with special needs prior to March 1, 2020, many said they gained additional caregiving responsibilities as a result of the pandemic (44% and 37% respectively).

Most mothers report the pandemic has taken a toll on their mental health. A majority of mothers of children under 18 (54%) say that worry or stress related to coronavirus has affected their mental health, significantly higher than men with children under 18 (35%) (Table 3). Three in four mothers characterize the impact as major or moderate, as do 55% of fathers. More than half of mothers who are employed (56%) say that pandemic-related stress and worry have affected their mental health, as do 50% of those who are not working. However, only 16% of mothers with children under 18 have sought mental health care, with a significant difference between those who are single (21%) and partnered (14%).

Conclusion

The COVID-19 pandemic has had a disproportionate impact on women in a number of ways. While many have had to put themselves and their families at risk to work on the frontlines as essential workers, a number of women have also had to take on new homeschooling and caregiving responsibilities that have placed additional burdens on their work or resulted in their leaving the workforce entirely. Disparities that existed prior to the pandemic have been magnified and a larger share of women of color and those who are low-income have had to quit their jobs, as well as take on additional caregiving responsibilities. As the nation begins to turn a corner on the pandemic, more schools are re-opening but many remain closed or with limited hours, still placing additional childcare burdens on parents and limiting the ability of many mothers to work at the same level as pre-pandemic. Furthermore, as more businesses reopen, women’s roles in the workplace will not necessarily be restored at the same pace. Some still have additional childcare responsibilities, some may be handling COVID-related illnesses for themselves or family members as well as the major mental health toll on women and their families. Some jobs may not be available anymore, some women had to scale back their workload and lost income, and many women will have missed out on career advancement opportunities. Policies such as paid leave and the child tax credit in the newly enacted federal stimulus bill can support women in caring for their families, obtaining needed health care and balancing work and family responsibilities in this unprecedented time.

The 2020 KFF Women’s Health Survey was designed and analyzed by researchers at the Kaiser Family Foundation (KFF) of a representative sample of 4,805 adults, ages 18-64 years old (3,661 women and 1,144 men). The survey was conducted online and telephone using AmeriSpeak®, the probability-based panel of NORC at the University of Chicago. U.S. households are recruited for participation using address-based sampling methodology and initial invitations for participation are sent by mail, telephone, and in-person interviews. Interviews for this survey were conducted between November 19 and December 17, 2020, among adults living in the United States. KFF paid for all costs associated with the survey.

The sample for this study was stratified by age, race/ethnicity, education, and gender as well as disproportionate stratification aimed at reaching uninsured women, women who identify as LGBT, and women 18-49 years old. The sampling also took into consideration differential survey completion rates by demographic groups so that the set of panel members with a completed interview for a study is a representative sample of the target population. Interviews were conducted in English and Spanish online (4,636) and via the telephone (169).

A series of data quality checks were run and cases determined to be poor-quality, as defined by surveys with a length of interview of less than 33% of the mean length of interview and with high levels of question refusal (>50%) were removed from the final data (n=96). Weighting involved multiple stages. First, the sample was weighted to match estimates for the national population from the 2020 Current Population Survey on age, gender, census division, race/ethnicity, and education. The second round of weights adjusted for the study’s sampling design. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample of women is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

1. People of Hispanic origin may be of any race but are categorized as Hispanic throughout this brief, while other groups are non-Hispanic. ↩︎
2. The federal poverty level (FPL) in 2020 was $26,200 for a family ofu00a0four.u00a0 ↩︎

Key Takeaways

• Women are more likely to have gone without health care during the pandemic compared to men, and women with health and economic challenges prior to the pandemic have experienced worsening health conditions as a result of skipping health care services during the pandemic. These gaps in care could translate into higher numbers of women experiencing severe health issues after the health emergency from the pandemic resolves.
• People have been largely satisfied with their telemedicine interactions.  The share of men and women who at the time of the survey reported having a telemedicine visit during the pandemic tripled since before the pandemic. But not all have had the opportunity or access to telemedicine. Older women, women with higher educational attainment, insured women, and women living in states that have expanded Medicaid are more likely to have had a telehealth visit during the pandemic. While telemedicine played an important role during the pandemic, is it still not clear whether it will continue to be an approach that providers and health consumers will continue to utilize at high rates as the risk of exposure to the coronavirus recedes.
• Women with private insurance and Medicaid are nearly twice as likely to have received a COVID-19 test compared to uninsured women (45% and 41% vs. 28%). Uninsured individuals may have been less likely to seek a test out of fear of cost, which could have implications for uptake of COVID-19 vaccines, even though all COVID-19 vaccines are free regardless of insurance status.
• The pandemic has had a significant effect on people’s mental health, with 51% of women and 34% of men saying that worry or stress related to the pandemic has affected their mental health. Most say that the impact has been moderate or minor, but almost one-fifth (21% women, 17% men) say the toll has taken a major impact on their mental health. The high need for mental health care has highlighted long-standing gaps in the availability and signals that the demand will likely continue as people begin to process the trauma and loss they have experienced over the past year.

Introduction

The COVID-19 pandemic transformed the way people access health care, with care quickly moving to telehealth. However, with fear of contracting the coronavirus and state emergency declarations limiting non-essential and elective services in the early days of the pandemic, many people have gone without health care services this year. The pandemic has highlighted and aggravated long-standing inequities in healthcare availability and access. This brief provides new data from the KFF Women’s Health Survey, a nationally representative survey of 3,661 women and 1,144 men ages 18-64 (Methodology) that was conducted November 19, 2020 – December 17, 2020. Among several topics related to women’s health and well-being, we asked respondents about experiences during the COVID-19 pandemic. In this brief, we document how experiences accessing health care during the COVID-19 pandemic have differed by gender, age, race/ethnicity, insurance coverage, and income and what this could mean moving forward.

Accessing Health Care During the COVID-19 Pandemic

A higher share of women than men have skipped recommended preventive services in response to the pandemic. When asked about their experiences accessing health care services during the pandemic, a larger share of women than men say they have skipped preventive health services, such as a yearly check-up or routine test (38% vs. 26%) or skipped a recommended medical test or treatment (23% vs. 15%). Nearly half of women who report being in fair or poor health report skipping preventive care (46%) and nearly one-third have skipped recommended tests or treatment (32%) compared to women who reported being in good, very good, or excellent health (36% and 21%, respectively). Those in poor health may view themselves as more at risk for COVID exposure and opt to skip routine preventive care. This gap in care among those with the greatest health problems could portend an increase of the share of patients experiencing more severe health conditions resulting from care that was foregone or delayed during the pandemic.

Surprisingly, women with incomes ≥200% of the federal poverty level (FPL) are more likely to have skipped preventive health services during the pandemic compared to women with incomes <200% FPL (40% vs. 33%, respectively),¹  as well as women with private insurance (39%) and Medicaid (38%) compared to uninsured women (30%). A larger share of women with private insurance (23%) and Medicaid (26%) also report skipping a recommended medical test or treatment compared to uninsured women (18%). In pre-pandemic times, the reverse was true, higher shares of women with lower incomes and who lacked insurance coverage reported skipping care. Women with more resources may be choosing to skip care because of concerns of COVID exposure.

Nearly one in five women in fair or poor health (18%) say they have either not filled a prescription, cut pills in half or skipped doses of medicine because of the COVID-19 pandemic, over twice the percentage of women in good, very good, or excellent health (8%). A higher percentage of low-income women < 200% FPL (14%), uninsured individuals (12%), and those with Medicaid (12%) also report not filling a prescription, cutting pills in half or skipping doses of medicine compared to higher income women (≥ 200% FPL) (8%) and individuals with private insurance (8%).ⁱ

More women than men report not being able to get an appointment because of the pandemic (30% vs. 20%), which could be a result of women being more likely to seek care. A larger share of women in poor or fair health (40%) compared to women in good or excellent health (29%) and low-income women (<200% FPL) (33%) compared to higher income women (≥ 200% FPL) (29%) say they were unable to get appointments. State emergency declarations limited services deemed non-essential or elective and reduced clinic hours and closures have made it particularly difficult to access care during the pandemic.

The pandemic has taken a disproportionate toll on some communities of color. Hispanic women, who have the highest rates of uninsurance, report higher rates of access barriers. Four in ten (40%) say they skipped preventive health services, 36% could not get a medical appointment, and 13% did not fill or skipped doses of prescription medicines because of the pandemic (Figure 2). Targeted outreach to this community regarding the COVID-19 vaccine will be important to ensure they have adequate access to and information about the vaccine, especially that the vaccine is free even without insurance.

Nearly one in 10 women ages 18-25 (8%) and 7% of women ages 26-35 say they delayed or were not able to get birth control due to the COVID-19 pandemic, which is significantly higher than women ages 36-49 (3%) (Figure 3). Women without a high school diploma were more likely to report delaying or not being able to get birth control compared to women with a Bachelor’s degree or higher (10% vs. 5%). Individuals who face delays in contraceptive care could face negative health consequences, such as sexually transmitted infections or unwanted pregnancies. While many clinics developed protocols to distribute contraception to their clients by reducing the need for in-person visits through telemedicine or other distribution approaches, addressing access for younger women and those with few resources will continue to be important.

Delays in accessing health care can translate into worsening health conditions, especially for women with underlying health problems that have been exacerbated by lack of care and those who face economic challenges that have gone without care due to cost. Among those who have skipped receiving health care services, women in fair or poor health, those with Medicaid coverage, and those with low incomes are more likely than other groups of women to report that their condition has worsened as a result of skipping care (Figure 4). Providers should be prepared to respond to greater health needs among their patients who have skipped care.

Telehealth

The rapid expansion of telehealth visits has broadened the ways in which people have been able to access care throughout the pandemic. Our survey defines telehealth/telemedicine as an appointment with a provider conducted by telephone or video conference in place of an in-person visit. For this survey, telemedicine or telehealth does not include email, messages sent through a website, or general online health information. Please see the survey topline for full question wording.

Prior to the pandemic, only about 1 in 10 men (11%) and women (13%) had received care via a telemedicine or telehealth visit. However, as of November/December when the survey was in the field approximately 1 in 3 men (32%) and women (38%) reported having a telemedicine or telehealth visit since March 1, 2020. Women over the age of 25, women with a college degree, insured women, and women living in states that have expanded Medicaid are more likely to have had a telehealth visit during the pandemic (Table 1).

Surprisingly, COVID-related care was not a leading reason for seeking health care through telehealth. Just 8% of women and 9% of men say their most recent telehealth appointment was for COVID-related symptoms. More commonly, women report their most recent telehealth visits were to address a minor illness or injury (21%), management of a chronic condition (18%), and 17% for mental health services. While similar shares of women and men report these reasons for telehealth visits, one notable difference is that one-quarter of men (26%) say their most recent telehealth visit was for a checkup, compared to 12% of women (Figure 5).

When asked to rate the care received at their most recent telemedicine or telehealth visit, most women showed high levels of satisfaction. A larger share of women rated the care they received at their most recent telemedicine or telehealth visit as excellent compared to men (35% vs. 29%). Telehealth care rated as excellent, very good, or good was more common among insured women with incomes ≥ 200% FPL compared to uninsured women with incomes < 200% FPL (91% vs. 86%) and women reporting being in excellent, very good, or good health compared to women who said their health was fair or poor (91% vs. 85%). There were no differences in ratings of telehealth quality by insurance status. Among women, telehealth mental health services received the largest share of excellent ratings and annual check-ups or well woman visits have the smallest share of excellent ratings, although ratings were still very positive with 89% of women rating their most recent telehealth annual check-up or well woman visit excellent, very good, or good (Figure 6). These data suggest most women are very satisfied with the telehealth services they have received and telehealth could continue to be a trusted approach to obtaining some types of health care services for individuals who would prefer or find it easier to access care from their home rather than traveling to a clinic or provider. However, there may be pressure from payers as the pandemic eases to once again limit telehealth due to cost concerns.

In recent years, there has been a proliferation of online companies that offer consumers access to primary care services, including sexual and reproductive health services like sexually transmitted infection testing, as well as prescriptions for everything from contraception to hair loss treatment. While these companies predate the pandemic, most are still relatively new. A small fraction of women (4%) ages 18-49 say they have ordered birth control from a website or app, like Nurx, The Pill Club, Pandia Health, or Planned Parenthood Direct. Younger women ages 18-35 (6%) in particular, are more likely to have ordered contraception from these companies compared to those ages 36-49 (1%). Some of these platforms do not accept insurance or Medicaid and may appeal to some uninsured or low-income women because of their costs. A larger share of Hispanic women (5%) compared to White women (3%) and low-income women (<200% FPL) (6%) compared to higher income women (≥ 200% FPL) (3%) have also used these online contraception platforms (Figure 7). While there is still a relatively small share of women using these online companies to obtain contraception, many of these companies have seen significant growth during the pandemic.

COVID-19 Testing

At the time that we fielded this survey in November-December 2020, four in ten women (42%) ages 18-64 had ever been tested for COVID-19 (Figure 8). Larger shares of younger women ages 18-49 (44%) had been tested compared to older women ages 50-64 (38%). Black (46%) and Hispanic (49%) women are also more likely to have been tested for COVID-19 compared to White women (39%).²  Women with private insurance and Medicaid have been nearly twice as likely to have received a COVID-19 test compared to uninsured women (45% and 41% vs. 28%), which could, in part, reflect uncertainty about or inability to afford out-of-pocket costs of COVID-19 tests without insurance. Women who reported having a regular provider are also more likely to have had a COVID-19 test compared to women who did not who do not have a regular health care provider (44% vs. 33%). Access to regular care results in more timely care and could also have implications for who is able to access COVID-19 vaccines, especially if documentation of a pre-existing condition is necessary for earlier vaccine groups.

A small percentage of women reported trying to get a COVID-19 test and being unable to get one (7%) (Figure 9). While a higher share of younger women report being tested for COVID-19, they are also more likely to report not being able to get a test (8%) compared to women ages 50-64 (5%), which may reflect that younger women are more likely to be seeking tests than older women. A larger share of Asian/Pacific Islander (11%) and Hispanic (9%) women say they were unable to get a COVID-19 test compared to White (6%) women, while the share of Black women (7%) who couldn’t get a COVID test is similar to White women. A higher percentage of low-income women (< 200% FPL) (9%) report being unable to get a COVID-19 test compared to higher income (≥ 200% FPL) women (6%).

Impact on Mental Health

Numerous aspects of the pandemic have caused worry and stress, including concern about exposure to an infected individual, not being able to get tested, losing loved ones and jobs, working from home, and taking on additional childcare and homeschooling responsibilities. Half (51%) of women and about one-third of men (34%) say that worry or stress related to the pandemic has affected their mental health. While most (79% women, 83% men) say that the impact has been moderate or minor, almost one-fifth (21% women, 17% men) say the toll has had a major impact on their mental health (Table 2). Women who are already in fair or poor health are more likely than women in better health to say that the pandemic has had a major impact on their mental health.

Despite the toll of the pandemic on women’s mental health, relatively few (15%) say they sought mental health care. While White women (54%) are most likely to say that stress from the pandemic has affected their mental health, Hispanic (19%) and Asian (19%) women are most likely to report seeking mental health care. Uninsured women (10%) are less likely to seek mental health care compared to women with Medicaid (20%) and private insurance (15%). There is likely to be a growing need for mental health care as people process the trauma and loss they have experienced over the past year.

Conclusion

The COVID-19 pandemic changed how people access and use health care, and while the availability of  options for telehealth care have grown rapidly and most people are satisfied with that care, it remains to be seen how acceptable these services will be as in person care resumes, and the requirements for payment parity are ended as the emergency measures are lifted by state and private sector payors. Many individuals are also having difficulties accessing care in this new environment or choosing not to seek care because of concerns about COVID exposure or risk. The survey finds that women have been more likely than men to forgo health care services during the pandemic, with many reporting worsening health conditions as a result. The expansion of telemedicine and virtual reproductive health care platforms have helped fill some of these gaps, but their reach is still limited, particularly for those without insurance or ready access to the internet or Wi-Fi. The burdens of the pandemic have had a negative impact on women’s mental health, though relatively few have reported seeking mental health care. Policies that promote stable insurance coverage, access to telehealth and mental health services, and the availability of safe in-person care can support women in obtaining needed health care for the remainder of the pandemic and beyond.

The 2020 KFF Women’s Health Survey was designed and analyzed by researchers at the Kaiser Family Foundation (KFF) of a representative sample of 4,805 adults, ages 18-64 years old (3,661 women and 1,144 men). The survey was conducted online and telephone using AmeriSpeak®, the probability-based panel of NORC at the University of Chicago. U.S. households are recruited for participation using address-based sampling methodology and initial invitations for participation are sent by mail, telephone, and in-person interviews. Interviews for this survey were conducted between November 19 and December 17, 2020, among adults living in the United States. KFF paid for all costs associated with the survey.

The sample for this study was stratified by age, race/ethnicity, education, and gender as well as disproportionate stratification aimed at reaching uninsured women, women who identify as LGBT, and women 18-49 years old. The sampling also took into consideration differential survey completion rates by demographic groups so that the set of panel members with a completed interview for a study is a representative sample of the target population. Interviews were conducted in English and Spanish online (4,636) and via the telephone (169).

A series of data quality checks were run and cases determined to be poor-quality, as defined by surveys with a length of interview of less than 33% of the mean length of interview and with high levels of question refusal (>50%) were removed from the final data (n=96). Weighting involved multiple stages. First, the sample was weighted to match estimates for the national population from the 2020 Current Population Survey on age, gender, census division, race/ethnicity, and education. The second round of weights adjusted for the study’s sampling design. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample of women is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

1. The federal poverty level (FPL) in 2020 was $26,200 for a family of four.u00a0 ↩︎
2. People of Hispanic origin may be of any race but are categorized as Hispanic throughout this brief, while other groups are non-Hispanic. ↩︎

As of February 2021, 12 states have not adopted the Affordable Care Act (ACA) provision to expand Medicaid to adults with incomes through 138% of poverty. Millions of people in these states remain without an affordable coverage option. Currently, the federal government covers 90% of the cost of Medicaid coverage for adults covered through the ACA expansion, a higher share than it does for other Medicaid enrollees. The American Rescue Plan Act of 2021 encourages non-expansion states to take up the expansion by providing an additional temporary fiscal incentive for states to newly implement the ACA Medicaid expansion. This brief provides illustrative estimates of the net fiscal benefit to states from these incentives relative to state costs under the expansion. We review the methods underlying these estimates in the Methods section at the end of the brief.

How does the fiscal incentive work?

Under the law, states would receive the 90% ACA match for the expansion population. Under the ACA, states currently receive a 90% federal matching rate (FMAP) for adults covered through the ACA expansion (this amount was 100% in 2014 and phased down to 90% over time). In states that have not expanded to date, adults who could be covered under expansion include about 4 million uninsured people (2.2 million with incomes under poverty in the “coverage gap” and 1.8 million currently eligible for marketplace coverage because their incomes are between 100% and 138% of poverty level). In addition, individuals with incomes 100-138% of the federal poverty level (FPL) who are currently enrolled in marketplace coverage would become eligible for Medicaid.

Under the law, states that do not have expansion in place when the bill was enacted would be eligible for a 5 percentage point increase in the state’s regular, or traditional, match rate (FMAP) for two years if they implement the expansion. The traditional FMAP applies to most services for non-expansion groups, including children, non-expansion adults, seniors, and people with disabilities. Even in states that have already adopted the expansion, the traditional Medicaid program is much larger – representing 79% of Medicaid spending overall in these states — and per enrollee costs are relatively higher than the expansion group. So, under this new incentive, states could draw down additional funds for a large share of their Medicaid population and spending if they newly expand. In addition to the 12 states that have not adopted the expansion, the increase in the match rate also applies to Missouri and Oklahoma because the bill was enacted before they implement the expansion in July 2021. Further, if states newly adopt the expansion in the near term, the new 5 percentage point increase would be in addition to the current 6.2 percentage point increase in the match rate provided under the Families First Coronavirus Response Act (FFCRA) that is tied to the Public Health Emergency (PHE). Based on a January 2021 letter from the Biden Administration to Governors, the 6.2 percentage point increase in the match will be in place at least through March 2022, halfway through federal FY 2023. While the enhanced match would be in place for two years after a state implements the Medicaid expansion, states can take advantage of this new option at any time.

What is the estimated effect on state spending?

We estimate that the increase in the traditional match rate would more than offset the increased state costs of the expansion in every state. Nationally, the increase in federal support from the 5 percentage point increase in the traditional match rate to the 12 non-expansion states could total $16.4 billion over two years if all states implemented the expansion starting in FY 2022. These new federal funds to states would be offset by new state costs tied to the 10% share of expansion. We estimate that new state costs for expansion could be $6.8 billion over two years across current non-expansion states, assuming all eligible people enroll. The result would be an estimated fiscal benefit to states of $9.6 billion over the two year period (Figure 1).¹  Put another way, new federal funds under the 5 percentage point bump are more than two times larger than new state expansion costs; this ratio varies slightly across states, from more than one a half times larger in Texas to over four times larger in South Carolina (Table 1).

After the two years, states would continue to receive the 90% match for the expansion group and the traditional match without the 5 percentage point increase for the traditional population. These estimates do not include additional federal funds that states would draw down through the 90% federal match on expansion spending, which would continue as long as the expansion is in place. States would continue to fund the 10% share of expansion and would lose the added fiscal incentive after two years. Research shows there are often savings in other state programs related to expanding Medicaid as well as revenue increases due to the infusion of federal funds associated with the 90% match on expansion spending. In addition, states could fund these ongoing costs with funds from the temporary enhanced FMAP that exceeded the cost of expansion; however, as states generally balance their budgets annually and may use the additional funds for other purposes, applying these funds to a later year may be difficult in practice.

These are illustrative estimates and subject to uncertainty. For example, the estimate of increased federal support from the enhanced match rate could be low if traditional Medicaid enrollment grows faster than our estimates assume, which may be possible given the pandemic and economic effects. In addition, the estimates of costs for new coverage could be high as we do not model take up but rather estimate costs for all eligible people; alternatively, the estimate for expansion could be low as it is based on national survey data that typically undercounts lower income people. Even with some uncertainty in the estimates, the magnitude clearly shows that the federal support would significantly outweigh the new costs of expansion while the temporary expansion incentive is in place. These estimates are not comparable to estimates from the Congressional Budget Office (CBO) that are capturing changes in federal spending over the next 10 years and incorporating behavioral responses that assume not all states would adopt the new option. The CBO estimates account for increased federal spending and reduced costs for federal subsidies in the Marketplace for states that adopt the expansion. CBO assumes that the option could increase federal spending by a net of $16.1 billion over the 2021-2030 period.

Medicaid expansion in the remaining 12 non-expansion states has the potential to reach millions of people. A comprehensive literature review of Medicaid expansion studies shows that expansion helps to expand coverage and reduce the uninsured, improve access to and utilization of care, reduce uncompensated care costs, improve affordability of care and reduce racial and ethnic disparities in coverage. The provisions in the American Rescue Plan Act would also provide substantial fiscal incentives for states to expand, which could be attractive given recent state revenue declines. However, given that the expansion incentive would be temporary, its effect may be limited.

Expansion Eligibility and Cost Estimates for Non-Expansion States

We calculate the number of people potentially eligible for Medicaid based on KFF 2019 estimates of the number of uninsured people who could be eligible for Medicaid if their state expanded plus estimates of people enrolled in Marketplace coverage who could become Medicaid eligible if their state expanded. We estimate Marketplace enrollees who could shift to Medicaid based on 2019 Marketplace enrollment data from the Centers for Medicare and Medicaid Services (CMS) Open Enrollment Period Files, and KFF analysis of the Census Bureau’s 2019 American Community Survey (ACS). We use Marketplace data on enrollees with income below 150% FPL, adjusted to the share with income through 138% FPL using KFF ACS estimates of income of people with nongroup coverage. To project spending on expansion adults for these states, we use our projected estimate of per enrollee costs for non-expansion adults in these states (described below) and apply the median ratio of spending per expansion enrollee to spending per non-expansion adult using data for expansion states for which we had a full year of data in FY2019.

We did not calculate additional state costs from expanding Medicaid for Missouri and Oklahoma because these states were scheduled to implement expansion in July 2021 and thus do not face new state costs due to expansion under the policy; rather, these costs are already assumed in the state Medicaid budget. Although we calculated the increased federal fiscal relief for Missouri and Oklahoma, we did not include them in the figures or nationwide estimates. We do not calculate new state costs for expansion in Wisconsin because the state currently provides Medicaid eligibility to childless adults earning up to the poverty level under a state waiver, at the regular FMAP; thus, even with additional costs due to covering currently marketplace-eligible people, the state would likely see fiscal gain under expansion by moving waiver enrollees from the regular state match to the 90% expansion match.

FY 2020 through FY 2023 Spending and Enhanced FMAP

We first estimate baseline spending without the new enhanced match rate. Our methods for baseline spending draw on those used in a previous brief on FMAP changes, updated to use more recent data sources where possible. We estimated baseline spending by using data from the 2019 Medicaid Budget Expenditure System (MBES), the Congressional Budget Office (CBO), the CMS Office of the Actuary (OACT), and the Medicaid and CHIP Payment Access Commission (MACPAC). Medicaid spending and enrollment do not include CHIP expenditures and do not include spending or enrollment changes due to economic effects from the coronavirus pandemic.

We use 2019 MBES data for baseline enrollment and spending for the expansion group and traditional Medicaid groups. For more information on how we calculate enrollment and spending from the MBES, please see our brief on expansion spending and enrollment. We distributed the enrollment and spending among traditional Medicaid groups (children, disabled, aged, and non-expansion adults) using MACPAC’s MACStats reports (Exhibits 14 and 21) based on 2018 TMSIS data. Then, we inflated enrollment from FY 2020 through FY 2023 using growth rates for each eligibility group from the OACT 2018 Actuarial Report on the Financial Outlook for Medicaid. We also inflate spending per enrollee through FY 2023 using an average of growth rates from OACT and the CBO March 2020 Baseline estimates. We averaged spending per enrollee growth from the CBO and OACT because the two estimates had substantial differences in annual growth rates for some enrollment groups, especially for 2019-2020. Finally, we multiplied enrollment and per enrollee spending estimates for each enrollment group to calculate a total spending baseline in FY 2020 and FY 2023, and then applied the FMAP adjustments to the total spending by state and eligibility group.

1. Total estimates do not include new federal funds or state costs for Missouri and Oklahoma, as these states already had plans to implement the expansion starting in July 2021 and thus do not face new state costs as a result of this policy. Further, we do not include new state expansion costs for Wisconsin, which has a waiver providing eligibility to childless adults earning up to the poverty level at the regular FMAP; thus, even with additional costs due to covering currently marketplace-eligible people, the state would likely see fiscal gain under expansion by moving waiver enrollees from the regular state match to the 90% expansion match. ↩︎