In this October 2020 post for The JAMA Health Forum, Ashley Kirzinger and Mollyann Brodie examine how the COVID-19 pandemic and other crises shook up the mix of issues voters care about without changing the 2020 presidential race’s core dynamic as a referendum on President Trump’s first term in office.

Other contributions to The JAMA Forum are also available.

As of October 16, Congress has enacted four emergency supplemental funding bills to address the COVID-19 pandemic, which collectively provide almost $3.2 billion for the global response. Of this amount, approximately $2.4 billion (75%) was designated for country, regional, and worldwide programming efforts through the State Department ($350 million), the U.S. Agency for International Development (USAID) ($1.24 billion), and the Centers for Disease Control and Prevention (CDC) ($800 million); the remainder was for operating expenses, including the evacuation of U.S. citizens and consular operations. With negotiations between Congress and the Administration over a fifth supplemental package on shaky ground, we examined the status of global COVID-19 country, regional, and worldwide funding to assess how much has been committed to date and where it has been directed.

Data were available to analyze virtually all (97%) of the $1.59 billion provided to State and USAID, specifically the funding that had been committed as of August 21, 2020.¹  The data also included $99 million in existing funding provided by USAID through its Emergency Reserve Fund for Contagious Infectious Disease Outbreaks (ERF),²  bringing the total to approximately $1.64 billion. Data were not available on funding provided to CDC, including data disaggregated by country or region.³ 

The analysis shows that:

• As of August 21, 2020, more than $1.6 billion has been committed by State and USAID to respond to COVID-19 globally, including virtually all (approximately $1.54 billion) of the funding provided through COVID-19 emergency supplemental appropriations and $99 million of existing funding from the ERF.
• Funding was first committed on February 7, through the ERF and before the passage of emergency supplemental funding bills. Funding commitments were next announced on March 27, soon after the first emergency supplemental bill was enacted, and announcements of commitments continued through August 21. See Figure 1.
• Most funding has been directed to Africa (30%), followed by Asia (17%), the Middle East and North Africa (13%), Latin America and the Caribbean (9%), and Europe and Eurasia (7%). An additional 25% is categorized as “worldwide” funding, which is not designated for a specific region or country at this time. See Figure 2.
• Funding has been committed to 117 countries (additional countries may be reached through regional and worldwide programming) to support a range of activities, including (but not limited to): case management, community engagement, disease surveillance, infection prevention and control in health facilities, laboratory systems capacity and preparedness, and risk communications. See Table 1.
• The ten countries with the largest funding commitments, by region, include:
  • Africa (4 countries: Ethiopia [which receives the greatest amount of funding], Nigeria, South Sudan, and Sudan);
  • Asia (2 countries: Afghanistan and Bangladesh);
  • the Middle East and North Africa (3 countries: Iraq, Jordan, and Lebanon); and
  • Europe and Eurasia (1 country: Italy, the only high income country in the top 10, receives the second greatest amount of funding – $50 million).

See Figure 3. These ten countries each received at least $35 million and together account for more than a quarter of funding ($444.3 million) committed by State and USAID.

1. State Department, “UPDATE: The United States Continues to Lead the Global Response to COVID-19” fact sheet, August 21, 2020. Data also provided by the State Department in response to a special data request from KFF in May 2020. Some but not all of this funding has been formally obligated; see Testimony of James Richardson, Director, Office of Foreign Assistance, State Department, during SFRC full committee hearing “Pandemic Preparedness, Prevention, and Response,” June 18, 2020, https://www.foreign.senate.gov/hearings/covid-19-and-us-international-pandemic-preparedness-prevention-and-response-061820. ↩︎
2. In earlier fiscal years, Congress has provided funding to the ERF at USAID to allow this funding to be made available to support future responses to any “emerging health threat that poses severe threats to human health.” See KFF, The U.S. Government and Global Health Security. ↩︎
3. CDC has posted broad information on how it plans to spend $300 million of the emergency funding; see CDC, “CDC COVID-19 Global Response,” webpage, updated Aug. 5, 2020, https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/global-response.html. ↩︎

A new KFF analysis examines leading causes of death and mortality rates in the United States and comparable countries.

The U.S. has a higher COVID-19 mortality rate than many of its peer countries, with COVID-19 ranking as the nation’s third-leading cause of death in 2020, behind only heart disease and cancer. Among similarly large and wealthy countries, only in Belgium does COVID-19 also rank as the third highest cause of death. COVID-19 ranks fourth in France, Sweden, and the United Kingdom, but much lower in Germany and Austria, where it ranks 17th and 18th respectively.

The analysis compares the number of COVID-19 deaths in each country through October 15th with annual deaths for other conditions in the most recent full year of data, generally 2017. On the heels of a CDC study finding nearly 300,000 excess deaths in the U.S., this KFF analysis looks at excess death data internationally, finding that the per capita rate of excess deaths in the U.S. is among the highest compared to similarly large and wealthy countries.

Prior to the pandemic, the U.S. had the highest overall mortality rate compared to peer countries. The coronavirus will likely widen the gap in mortality rates between the U.S. and its peer countries, both due to the higher number of deaths directly attributed to COVID-19 in the U.S. compared to peer countries, as well as due to causes potentially exacerbated by the pandemic, including delayed or forgone care.

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

A new KFF brief looks at where COVID-19 falls as a leading cause of death in the U.S. compared to similarly large and wealthy countries. The analysis finds that COVID-19 mortality rates are the third leading cause of death in the U.S., a ranking shared by only one peer country, Belgium. In several other peer countries, including Australia and Germany, COVID-19 is not close to breaking into the top 10 leading causes of death.

The brief also addresses high per capita excess deaths in the U.S. – the number of deaths exceeding what is expected in a typical year.

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

In this perspective published by the Washington Post, KFF Executive Vice President for Health Policy Larry Levitt explains why the popular Affordable Care Act provisions that ensure people with pre-existing conditions can access affordable health insurance can’t easily be preserved if other related provisions are overturned.

As the 2020 Election Day approaches, many candidates continue to focus on health care issues, including on the public health and economic response to COVID-19, the future of the Affordable Care Act, health care costs and abortion.

To help reporters understand and cover these issues, KFF offers independent, non-partisan policy analysis, polling and other research and has experts who can provide context, explain trade-offs and provide key data points on health care issues that may arise in the debates and broader campaign. Some key resources:

Overview

• This overview slideshow compares President Trump’s record and Democratic nominee Biden’s positions across a wide range of key health issues. This JAMA Health Forum column also summarizes key differences.
• This brief reviews the Trump administration’s record on a wide range of health issues.
• The October KFF Health Tracking Poll assesses voters’ views of the presidential candidates on key health care issues. The KFF/Cook Political Report’s Sun Belt Voices Project polls voters in Arizona, Florida and North Carolina, three critical battleground states.
• These health care snapshots provide state-specific health policy data on costs, Medicaid, Medicare, private insurance, the uninsured, women’s health, health status, and access to care.

COVID-19

• This overview and detailed side-by-side compares President Trump and Democratic nominee Biden on their records, actions and proposals related to the COVID-19 pandemic.
• Our September poll examines the public’s knowledge and views of the coronavirus outbreak, and their trust in public health experts and institutions, including concerns about how political pressure may affect vaccine development.
• KFF President and CEO Drew Altman’s essay in The BMJ examines two fundamental policy decisions made by the Trump administration that set the U.S. on the controversial and highly criticized course it has taken on COVID-19.
• This topic page highlights several pieces on how people of color have fared worse during the pandemic and also provides data on underlying health care disparities and racial inequities.
• The post looks at how insurers could treat COVID as a pre-existing condition if the federal protections in the ACA were overturned as a result of a pending case before the Supreme Court.

Affordable Care Act and Coverage Expansions

• This explainer examines the potential impact of the Texas v. California case, supported by the Trump administration, that aims to overturn the ACA. The U.S. Supreme Court is scheduled to hear the case on Nov. 10, a week after the election. This analysis examines key provisions of the law and how they impact nearly every American, with national, state, and public opinion data.
• This analysis estimates the number and share of people by state with pre-existing conditions that would have prevented them from buying health insurance based on the underwriting practices in place in most states prior to the ACA. This post looks at variation by age, gender and in and outside metro areas.
• This analysis examines the impact of expanding ACA premium subsidies as Democratic nominee Biden has proposed on the cost of Marketplace coverage.
• This post looks at what we know about recent trends in health insurance coverage. This report assesses the effects of the ACA’s Medicaid expansion on coverage, access to care, state budgets, and the economy.
• This brief provides key public opinion data about the public’s views and knowledge about the ACA.

Prescription Drug and Health Costs

• This slideshow explains the similarities and differences among major proposals to lower prescription drug costs introduced by the Trump Administration, members of Congress, and the Biden campaign.
• This explainer examines key issues regarding importation of drugs from Canada and other countries.
• This brief looks at Medicare negotiation of drug prices.
• This analysis estimates how often consumers receive surprise medical bills when getting emergency room and hospital care, and describes key proposals to protect consumers. This brief looks at the chance of getting an unexpected out-of-network medical bill for different health conditions, including heart attacks and mastectomies.
• This slideshow captures key polling data on Americans’ views and experiences with prescription drug costs, and this data note looks at Americans’ experiences with surprise medical bills.

Abortion and Reproductive Health

• This brief looks at the potential implications of the presidential election on women’s health issues, while this one summarizes four state ballot initiatives related to abortion, sex education and paid leave.
• This poll explores the public’s views and knowledge about abortion and reproductive health issues, including Roe v. Wade, state-level restrictions, and family planning services.
• This analysis examines the likely impact of Trump administration regulations, currently blocked by court orders, for abortion coverage in ACA marketplace plans.
• This slideshow looks at the impact of state abortion policies on clinical practice.

If you have questions about any of these resources or want to talk to a KFF expert, please contact Rakesh Singh, Craig Palosky or Chris Lee for assistance.

On June 12th, the Trump Administration released a final regulation implementing Section 1557 of the Affordable Care Act, and revising an Obama era rule. In it, the administration removed explicit nondiscrimination protections based on gender identity and sexual orientation in health care. In light of a recent Supreme Court decision, and based on other legal grounds, five lawsuits are currently challenging the Trump Administration rule and blocking its implementation. If the explicit protections provided under the Obama era rule are lifted, it could be easier for health care providers to refuse to see individuals who are transgender or who do not conform to traditional sex norms. Explicit protections on the basis of sexual orientation and gender identity could have significant and lasting implications for LGBTQ people, including the estimated 1.4 million transgender adults living in the US.

This analysis seeks to better understand the experiences of transgender people in the US health care system. We examine the demographic characteristics of transgender adults ages 18 and over and their access to health care. We analyzed pooled, cross-sectional data from a subset of the 2017 and 2018 Behavioral Risk Factor Surveillance System (BRFSS). We consider adults to be transgender based on their response to survey questions and define all other adults to be cisgender.

Key Takeaway

Our analysis finds that transgender adults are more likely to be uninsured (19% vs. 12%) and report cost-related barriers to care (19% vs. 13%) than cisgender adults. Transgender adults are also more likely to be non-Hispanic Black and low income than cisgender adults (Figure 1).

Findings

DEMOGRAPHICS

• Age. A much larger share of transgender adults are under age 35 (44%) than cisgender adults (27%) with one in four (25%) transgender adults under age 25 (data not shown). At the other end of the age spectrum, 16% of transgender adults are 65 years old or older, compared to 22% of cisgender adults (Figure 2).

• Education. Transgender adults report fewer years of education compared to cisgender adults, holding age constant (analysis not shown). Nearly one quarter of all transgender adults (23%) have less than a high school education compared to 13% of their cisgender peers. A smaller share of transgender than cisgender adults graduated from college or technical school (15% vs. 27%, respectively).
• Race/Ethnicity. While a majority of transgender and cisgender adults are white, a larger share of transgender than cisgender adults are Black (16% vs. 12%, respectively).
• Annual Household Income. A larger share of transgender than cisgender adults live on lower incomes: 25% of transgender adults report an annual household income under $20,000 compared to 15% of cisgender adults, based on income reported for 2017-2018 (Figure 3). Transgender adults are more likely to report an annual income under $20,000 holding age constant (analysis not shown).

• Employment Status. Among adults still in the labor force, a higher share of cisgender adults report being employed compared to transgender adults (56% vs. 48%, respectively). Nearly one in ten (9%) of transgender adults report they were unemployed from 2017-2018, a share much higher than that of cisgender adults (5%). 

HEALTH STATUS, INSURANCE COVERAGE, AND ACCESS TO CARE

• Health Status. Transgender adults are more likely than cisgender adults to report being in poor health (10% vs. 5%, respectively).
• Lifetime Depression. Transgender adults report lifetime depression at twice the rate of cisgender adults (38% vs. 19%, respectively) (Figure 4).

• Health Insurance Coverage. A larger share of transgender than cisgender adults (19% vs. 12%, respectively) report that they were uninsured over the 2017-2018 period.
• Cost-Related Barriers to Care. Nearly one in five (19%) transgender adults report experiencing barriers to care due to cost, more than the share reported by cisgender adults (13%).
• Personal Doctor. A similar share of transgender (22%) and cisgender (21%) adults report that they do not have a personal doctor or health care provider.
• Time Since Last Checkup. A similar share of transgender and cisgender adults report having gone more than one year since their last checkup (25% vs. 24%, respectively).

Discussion

Our analysis finds that transgender people differ from cisgender adults in a number of ways that could impact their health care, as a backdrop for understanding the potential implications of lifting anti-discrimination protections. Transgender adults are younger, less educated, have lower incomes, are in poorer health, with higher rates of lifetime depression, and are less likely to be white, employed and have health insurance. Transgender adults are also more likely than cisgender adults to experience barriers to care due to cost. In other ways, barriers to care faced by transgender people are similar to those faced by cisgender people.

Past research shows that younger adults report lower incomes, and that people of color are also more likely to be uninsured, which may  explain some of the differences in demographic characteristics and insurance coverage. However, it has also been suggested that demographic differences alone do not completely explain why transgender adults experience more difficulty in accessing care in certain circumstances than their cisgender peers do.

Our analysis suggests that transgender adults experience barriers to care even with the Section 1557 health care protections based on gender identity in place. Removing these protections may exacerbate already-existing access problems, which may lead to increased barriers to care among these adults, at a time when access to health care is critical.

A new KFF issue brief examines the implications of a Supreme Court with a solid conservative majority. Two abortion cases have pending requests for Supreme Court review: Dobbs v. Jackson Women’s Health Organization and FDA v. ACOG. If the Court chooses to take these cases, abortion laws and who can legally challenge them could be affected in major ways, including:

• The option for doctors and clinics to challenge laws regulating abortion on behalf of their patients could be eliminated, and only patients themselves could challenge the laws.
• The constitutional right to an abortion established in Roe v. Wade could be overturned allowing states to ban or further restrict abortion.
• The legal standard for evaluating abortion laws’ constitutionality could be changed.

Read the brief, Abortion at SCOTUS: A Review of Potential Cases this Term and Possible Rulings, for the detailed history and legal issues in question for the two abortion cases pending the Supreme Court’s review.Also available is A Reconfigured U.S. Supreme Court: Implications for Health Policy, for a broader discussion on health care cases to be reviewed or potentially coming before the Court in the current term.

The confirmation process for Judge Amy Coney Barrett, President Donald J. Trump’s appointment to fill the Supreme Court seat previously held by Justice Ruth Bader Ginsburg, began last week with the fate of the Affordable Care Act (ACA) firmly at the center of the hearings. With the Supreme Court set to hear arguments in California v. Texas only days after the election, the nomination of Judge Barret has placed heightened scrutiny on what President Trump’s administration would do to continue the ACA’s protections for people with pre-existing conditions if the Supreme Court invalidates the law.

The October KFF Health Tracking Poll finds that a large majority of the public – including majorities of Democrats (91%), independents (81%), and Republicans (66%) – now say they do not want to see the Supreme Court overturn the ACA’s pre-existing condition protections. The share who do not want to see these protections overturned has increased by double digits from one year ago for each group. While both presidential candidates – President Trump and former Vice President Joe Biden – say they have plans to ensure pre-existing condition protections, more than half (53%) of the public say they “do not think President Trump has a plan to maintain protections for people with pre-existing health conditions,” including majorities of Democrats (90%) and independents (57%). On the other hand, a large majority of Republicans (85%) say President Trump “has a plan” to maintain these protections afforded by the ACA.

In 2020, Trump signed an executive order – a statement of goals — promising to protect people with pre-existing conditions, but has offered no plan to do so. This order is not a binding rule or law. President Trump has not provided further details.

Source

KFF Health Tracking Poll – October 2020: The Future of the ACA and Biden’s Advantage On Health Care

Government officials hope to identify one or more safe and effective COVID-19 vaccines over the next few months as part of a multi-agency effort known as Operation Warp Speed. If and when they succeed, their focus will shift to making sure people across the country can access the vaccine.

A new issue brief lays out some of the key challenges with such a massive vaccination effort, which could require hundreds of millions of vaccine doses to be delivered across the country in a short period of time. The brief describes the leading vaccine candidates for the U.S. and what’s known about the federal government’s plans for distributing a successful vaccine or vaccines across the country and the challenges, including the potential need for billions of dollars in additional funding.

It also examines issues around supply, logistics and monitoring; the role of the federal, state and local governments; insurance coverage and out-of-pocket costs; racial and ethnic disparities; and building public confidence about the vaccine’s safety and effectiveness.

The brief is part of KFF’s broader portfolio examining the health and economic impacts of the COVID-19 pandemic, including original policy analysis, polling and journalism.