Coronavirus: Reopening, Schools, And The Government Response

Key Findings

• Amid a surging coronavirus pandemic and record numbers of new cases in many states, the latest KFF Health Tracking Poll finds most U.S. adults feel the worst effects of the pandemic are yet to come, and seven in ten (including four in ten Republicans) rate the federal government response to the pandemic as fair or poor. The survey also indicates that the pandemic is increasingly taking an emotional toll, with a majority of U.S. adults (53%) saying that worry and stress related to coronavirus has had a negative impact on their mental health, up from 39% in May.
• With Congress set to consider its next coronavirus relief package, a clear majority of the public across political party affiliation says that top priority should be given to increasing federal funding for efforts to limit the spread of the virus such as testing, contact tracing, and personal protective equipment for essential workers. Most Democrats, and about half of independents and Republicans, also say Congress should prioritize increasing federal support for state and local governments to help schools reopen safely. Large shares of the public also see various measures to bolster individuals’ financial health and increase access to health insurance amid the economic downturn as important things for Congress to tackle, though partisans divide on the priority that should be placed on these measures.
• With the new school year quickly approaching, the issue of whether and how to reopen schools looms large for both parents and policymakers. On balance, most parents with kids in school (60%) say it is better to open schools later to minimize infection risk, even if students miss out on academics and social services and some parents will not be able to work, while about half as many (34%) say it’s better to open schools sooner so parents can work and kids can get services, even if there’s some risk of infection. A majority (71%) of the public overall say that public schools in their area need more resources to reopen safely, and 66% of parents say the same about their own child’s school. Parents of color are more likely than White parents to say it is better for schools to open later to minimize infection risk, and to say that their own child’s school lacks the resources it needs to reopen safely.¹ 
• Parents – particularly parents of color and those with lower incomes – have a variety of worries related to both a school reopening scenario, and one in which schools remain closed. When it comes to reopening, majorities are worried that their child, family members, or teachers may get sick from the virus, and most also worry about schools’ and students’ ability to comply with physical distancing and other public health guidance. If schools don’t reopen, about two-thirds of parents are worried about their children falling behind socially and emotionally (67%) and academically (65%), and about half worry about losing income if they can’t go to work (51%) or not being able to pay enough attention to their kids if they’re working at home (47%). The inability to access other services schools provide is a concern for some parents: 40% worry about their child not getting needed social services if schools remain closed, 31% worry they won’t have access to technology needed for online learning, and 24% worry about their children having enough food to eat at home. Many of these worries – both about the risks of school reopening and the loss of learning and social services – are much higher among parents of color and those with lower incomes than they are among White and higher-income parents.
• The latest KFF Health Tracking Poll also finds that more than four months in, the coronavirus pandemic continues to take an economic toll on Americans. Four in ten report trouble affording basic necessities or falling behind on household or medical bills in the past 3 months, including 22% who say they experienced this directly because of coronavirus and its impact on their financial situation, and 17% who say they were experiencing these problems before coronavirus.

View On The State Of The Pandemic And Government Response

With a mounting death toll and coronavirus cases surging throughout much of the U.S., a majority of the public (60%) think that the worst is yet to come, up from 50% in May, though not as high as the 74% of adults in early April who thought things were likely to get worse. One in five adults (20%) currently think that the worst of the coronavirus outbreak is behind us. The overall numbers mask a deep partisan divide, with a slight majority of Republicans saying either “the worst is behind us” (31%) or that they don’t think the coronavirus is or will be a major problem (23%), while about eight in ten Democrats (79%) and a majority of independents (57%) say “the worst is yet to come.”

Amid what many see as a botched federal response to the virus, about half of U.S. adults (48%) rate the federal government response to the pandemic as “poor” while another 23% call it “fair.” Just 28% rate the federal response as “good” or “excellent.” Even among Republicans, who are generally supportive of President Trump and his Administration, 42% rate the federal government response to the pandemic as “fair” or “poor.” The public is more divided when it comes to assessing state and local governments, with about half of adults giving their state (46%) and local (48%) governments positive marks.

Majorities Across Parties Say Congress Should Prioritize Funding For Testing And Contact Tracing

As Congress discusses its next coronavirus relief package, there are reports that the Trump Administration is resisting allocating additional federal funds for coronavirus testing, contact tracing, and other prevention measures. This is at clear odds with the public’s priorities; when asked about a number of potential actions Congress could take, the highest-ranked priority among the public is increasing federal funding for efforts to limit the spread of coronavirus, such as testing, contact tracing, and personal protective equipment for essential workers. Seven in ten adults overall (72%) say this should be a top priority for Congress, including majorities of Democrats, independents, and Republicans. Schools are another popular priority: a majority (55%) say increasing federal funding to state and local governments to help schools reopen safely should be a top priority, including about two-thirds of Democrats (68%) and about half of independents (53%) and Republicans (48%).

Other measures to provide economic relief or extend insurance benefits are seen as important by large shares of the public overall, but have less broad appeal across partisans. For example, about half the public overall say increasing government financial assistance to help Americans who do not get health insurance from their jobs pay for coverage (52%) and providing financial assistance for people who have lost their jobs to purchase COBRA insurance through their former employers (49%) should be top priorities. However, there are large partisan gaps, with Democrats 42 percentage points more likely than Republicans to say Congress should place a top priority on increasing government financial assistance for individual health insurance, and 26 percentage points more likely to say Congress should place a top priority on providing assistance for people to purchase COBRA coverage.

About four in ten overall say other actions should be top priorities for Congress, including increasing funding to states to help pay for Medicaid (44%), sending a second round of stimulus checks to individuals (43%), guaranteeing every American a basic income until the pandemic passes (42%), creating a public option health insurance plan (41%), and extending the additional unemployment benefits set to expire at the end of July (39%). Views on each of these measures are marked by large partisan differences, with about six in ten Democrats saying each should be a top priority, compared with about a quarter of Republicans.

Views On The Pace Of Reopening, Including Schools

With coronavirus cases surging in many states that took an early approach to reopening, a plurality (45%) of adults overall say their state is moving at about the right pace in easing social distancing restrictions and opening businesses, while three in ten (31%) say their state is moving “too quickly” and about one in five (22%) say their state is opening “too slowly.” Views on reopening vary by both partisanship and location. Democrats are about three times as likely as Republicans to feel their state is moving too quickly, while Republicans are about three times as likely as Democrats to feel their state is moving too slowly. Notably, about four in ten adults (39%) in states that are current coronavirus hotspots (based on case data as of July 18) say their state is moving too quickly to reopen, compared to about one in four (24%) in non-hotspot states.² 

Public And Parents Prefer To Delay School Openings To Mitigate Risk

With the new school year quickly approaching, the issue of whether and how to reopen schools for in-person instruction has been at the forefront of discussions for both parents and policymakers. President Trump has stated that he wants schools to reopen for in-person instruction in the fall, and has even suggested that the federal government may withhold money from schools that don’t reopen. When asked to weigh the risks vs. benefits, a majority of the public (63%) thinks it is better to open schools later to ensure the risk of getting coronavirus is as low as possible, even if it means some students will fall behind academically or miss out on services and some parents will be unable to return to work. About a third (32%) think it is better to open schools sooner so that parents can work and students won’t miss out on learning and other services, even if there is some risk to teachers, students and staff. There is a large partisan gap on this issue among the public overall, with 87% of Democrats and 59% of independents preferring schools open later while six in ten Republicans (60%) prefer that schools open sooner.

Among parents with a child age 5-17 that normally attends school, six in ten (60%) think it is better to reopen schools later in order to ensure the risk of coronavirus is as low as possible, while about half as many (34%) think it is better to reopen sooner. Parents of color (76%) are even more likely to prefer a later reopening compared to their White counterparts (51%).

The public’s caution towards reopening schools may be reinforced by a sense that schools do not have the necessary resources to safely reopen in a manner that complies with public health recommendations on how to minimize the risk of spreading coronavirus. Seven in ten adults overall say that public schools in their area need more resources in order to safely reopen, while just 22% say schools have enough resources. This sentiment is echoed by parents of school-aged children when they are asked about their own child’s school. Two-thirds of parents (66%) say their child’s school needs more resources in order to safely reopen. Notably, parents of color are more likely than their White counterparts to say their child’s school lacks the resources necessary to safely reopen (82% vs. 54%).

Parents – Particularly parents of color and those with Lower Incomes – Worry about both school reopening And remaining closed

With many schools’ academic year commencing in August and early September, about half of parents with children who typically attend school (52%) said their child’s school had not yet announced whether they would be having in-person classes this fall at the time they took the survey. This month’s poll asked parents about worries related to both a school reopening scenario and one in which schools remain closed to in-person instruction. When it comes to reopening, large shares of parents with a child enrolled in school are worried about teachers and staff getting sick from coronavirus (79% very or somewhat worried) and children being unable or unwilling to comply with physical distancing practices (73% very or somewhat worried). About seven in ten are also worried about their child (70%) or themselves or a family member (69%) getting sick from coronavirus, while two-thirds (66%) worry about their child’s school being unable to comply with public health recommendations.

Reflecting the disproportionate impact of the coronavirus pandemic on those with lower incomes and on communities of color, there are some notable differences in worry levels between parents of color and White parents, and between those with lower and those with higher household incomes. Nine in ten parents of color (91%) say they are either “very worried” or “somewhat worried” about their child getting sick with coronavirus if they return to school in the fall, compared to 55% of White parents who say the same. Similarly, about nine in ten of parents of color say they are worried about teachers and other staff getting sick with coronavirus (92%), children being unable or unwilling to physically distance (91%), and that they or a family member will get sick with coronavirus (90%). Far fewer White parents say they are worried about each of these concerns.

In addition, parents who have a household income under $90,000 are more likely than their higher-income counterparts to say they are worried about children being unable or unwilling to physically distance (82% vs. 62%) or teachers and staff getting sick from the coronavirus (84% vs. 73%).

Parents also express a number of worries related to schools remaining closed for in-person instruction in the fall. If schools don’t reopen, about two-thirds of parents say they would worry about their children falling behind socially and emotionally (67%) and academically (65%), and about half say they would worry about losing income if they can’t go to work (51%) or not being able to pay enough attention to their kids if they’re working at home (47%). Other services schools provide are also a concern for some parents: 40% worry about their child not getting needed social services if schools remain closed, 31% worry they won’t have access to technology needed for online learning, and 24% worry about their children having enough food to eat at home.

Similar to the findings on parental worries about their child returning to school in-person in the fall, parents of color and those with lower household incomes are also more likely than their counterparts to say they worry about possible outcomes if their children do not return to in-person classes.

Parents of color are more likely than White parents to say they are “very worried” or “somewhat worried” about their child not getting social services they usually get at school (52% vs. 32%), are almost three times as likely to worry their child won’t have access to the technology needed for online learning (49% vs. 17%), and about five times as likely to worry their child will not have enough to eat at home (44% vs. 9%). Parents of color are also more likely than White parents to worry about losing income if they are unable to work outside the home (65% vs. 41%).

Similarly, parents with household incomes under $90,000 more likely than their higher income counterparts to be worried that their child will not have access to social services they usually get at school (47% vs. 26%), will not have enough to eat at home (34% vs. 6%), or won’t have access to the technology needed for online learning (43% vs. 10%). Moreover, lower-income parents are more likely than those with higher incomes to worry about losing income if they are unable to work outside the home (61% vs. 35%).

The Continuing Impact Of The Coronavirus Pandemic On Mental Health, Wellbeing, And Financial Health

over half report a negative impact on mental health

As life with the coronavirus pandemic wears on, Americans increasingly say it is taking a negative toll on their mental health. For the first time since KFF began tracking this question in March, a majority of adults (53%) now say that stress and worry related to the pandemic has had a negative impact on their mental health. This is up 14 percentage points since May, and up 8 percentage points since the previous high of 45% in early April. About one in four (26%) say worry and stress related to coronavirus has had a “major impact” on their mental health, while a similar share (28%) say it has had a “minor impact.”

Notably, younger adults are more likely older adults, and women are more likely than men, to say stress and worry related to coronavirus has had a negative impact on their mental health. About seven in ten Blacks adults (68%) and those who have had difficulty paying household bills in the past three months due to the financial impact of the coronavirus outbreak (71%) say that stress and worry related to the pandemic has had a negative impact on their mental health.

In addition to reporting a general negative impact on their mental health, about half (52%) of adults report that worry and stress related to the coronavirus outbreak has had adverse effects on their mental health and wellbeing in specific ways. About a third say coronavirus-related worry or stress has led to problems with their sleep (36%) or has led to a poor appetite or overeating (32%). About one in five say worry or stress related to the pandemic has caused them to experience frequent headaches or stomachaches (18%) or difficulty controlling their temper (18%), while 12% each say it has led to increased alcohol or drug use or worsening chronic health conditions.

Mirroring the findings on overall negative impact on mental health, younger adults and women are more likely than their counterparts to say coronavirus-related stress has caused adverse effects on their mental health or wellbeing. Notably, three in four adults who have had difficulty paying household bills in the past three months due to the financial impact of coronavirus say they have also experienced adverse effects their mental health and wellbeing, as do about six in ten Hispanic adults and Black adults.

four in ten have problems affording household expenses or health care

With the country facing a double-digit unemployment rate, four in ten adults say they or an adult in their household has had problems paying bills or difficulty affording medical care or basic expenses in the past three months. This includes about one in five who say they have fallen behind on their credit card bills (22%), 18% who have had trouble affording health insurance, and similar shares who say they have had trouble paying medical bills (17%), paying for food (17%), paying utility bills (17%) or have fallen behind on their rent or mortgage (17%). Additionally, 12% say they have had problems affording their prescription medications. Notably, among the 40% of adults who have experienced difficulty paying household or medical bills in the last three months, most (54%, or 22% of all adults) say it was due to the coronavirus outbreak and its impact on their financial situation, while 42% (17% of all adults) say this something they were already experiencing before the pandemic.

Coronavirus and the 2020 Election, ACA

Key Findings

• Less than four months before the 2020 presidential election, the latest KFF Health Tracking Poll finds President Trump receiving his lowest ratings ever from voters on his handling of the coronavirus outbreak. President Trump still garners majority support from Republican voters on all key issues.
• With the number of coronavirus cases in the U.S. now exceeding 4 million people, nearly twice as many voters give President Trump negative marks on his handling of this issue as give him positive marks (61% v. 35%).
• The July poll also explores how two key groups of voters for the 2020 election (swing voters and Electoral College battleground voters) view the job President Trump is doing. About half of these voters approve of President Trump’s handling of the U.S. economy, but similar to overall voters, they disapprove of his handling of other issues.
• President Trump also receives low marks on his handling of health care and the Affordable Care Act, the 2010 health care law which the Trump administration is currently challenging in court. About one-third of voters say they approve of the president’s handling of health care generally (35%) and the Affordable Care Act specifically (33%). Partisans have very different views on President Trump’s handling on both of these issues with most Democrats disapproving while majorities of Republicans approving.
• The public’s views of the Affordable Care Act have largely remained unchanged over the course of the coronavirus pandemic, with half of the public continuing to view the law favorably. There are strong partisan differences in how the public views both the ACA and the pending Supreme Court case challenging the legality of the 2010 law, with Republicans overwhelmingly wanting to see the law overturned while most Democrats want to see the ACA remain in place and largely disapprove of recent Trump administration actions challenging the law.

The 2020 Election

Four months out from 2020 election, voters give President Trump negative ratings on his overall job approval as well as his handling of key issues that will likely decide the election President Trump also now garners his lowest net approval on the handling of the coronavirus outbreak in the U.S. since KFF began polling on the topic. One-third (35%) of voters approve of his handling of the coronavirus outbreak in the U.S. while six in ten (61%) voters disapprove (net approval of -26 percentage points). President Trump also receives negative ratings on his handling of health care more broadly (net approval of -21 percentage points) as well as his handling of the Affordable Care Act (net approval of -21 percentage points). While President Trump had previously received positive marks on his handling of the economy, voters are now split with 47% approving of his handling of the nation’s economy, and 50% disapproving (resulting in a negative net approval—approval minus disapproval—of -3 percentage points). Overall, four in ten voters (41%) approve of how President Trump is handling his job as president while a majority disapprove (56%).

Voters’ attitudes on President Trump’s handling of both the economy and the coronavirus outbreak have dropped sharply since May 2020. The latest KFF Health Tracking Poll finds President Trump’s overall net approval on these two key issues has dropped nearly 20 percentage points over the course of the summer (economy: 19 percentage point drop in net approval; coronavirus: 18 percentage point drop in net approval).

Voters’ opinions of President Trump’s handling of the issues probed in the poll are largely partisan, with Republicans giving him much higher marks across all of the issues asked about. Majorities of Republican voters approve of President Trump’s handling of his job as president (84%), the economy (87%), health care (78%) and the coronavirus outbreak in the U.S. (74%), yet his net approval on each of these issues is down by double digits among Republicans since May.

2020 Voters to Watch: Swing Voters

Swing voters, a crucial group of voters who have not yet decided which candidate they will vote for in November, are also negative in their assessments of President Trump’s presidency and his handling of most national issues – but remain positive in their assessment of his handling of the economy. Swing voters (who comprise 29% of all voters) largely disapprove (57%) of the way President Trump is handling his job overall and are also negative in Trump’s handling of both the coronavirus outbreak (66% disapprove) and health care (58% disapprove).

Swing voters are more positive in views of how President Trump is handling the economy, but at a smaller margin than their assessments in May, with a net approval of +5 percentage points compared to +19 percentage point net approval in May. Swing voters’ assessments of Trump’s handling of health care and the coronavirus outbreak have also become more negative, with the assessments of the president’s handling of health care down 8 net percentage points, and the current coronavirus outbreak down 14 net percentage points.

2020 Voters to Watch: Electoral College Battleground Voters

Another important group of voters to watch in 2020 are voters living in states where the election outcome is less predictable. The attitudes of these Electoral College battleground voters will be important in the upcoming election, as their states and districts are likely to swing the Electoral College towards President Trump or Joe Biden.³  This group of voters, representing 38% of all voters, are evenly split in their party preferences, with three in ten saying they are Democrats, Republicans and Independents (31%, 30% and 31% respectively).

President Trump fares slightly better with these battleground voters on all key issues. Half of these voters approve of President Trump’s handling of the economy and 45% say they approve of his handling of his job as president. But similar to the views of all voters and swing voters, President Trump fares slightly worse on his handling of health care and the coronavirus outbreak in the U.S.. Partisan voters in these battleground states and districts fall largely along the same party lines in their evaluations of President Trump, as partisan voters overall.

The Affordable Care Act

The public’s attitudes towards the 2010 Affordable Care Act (ACA) have remained relatively unchanged over the past 5 months, with half (51%) now saying they hold a favorable opinion of the law, while 36% hold an unfavorable view.

Partisans continue to hold different views of the ACA, with about eight in ten Democrats (79%) holding favorable views while seven in ten Republicans (72%) view the law unfavorably. Half of independents hold favorable views (51%) while a smaller share (35%) say they view the law unfavorably.

On June 25^th, 2020, the Trump administration issued a brief asking the U.S. Supreme Court to overturn the entire Affordable Care Act. The brief was filed in support of an ongoing challenge to the ACA by a group of Republican attorneys general in California v. Texas, a case that challenges the legality of the ACA in light of the zeroing out of the individual mandate penalty in the 2017 Tax Cuts and Job Acts. While there is a possibility that the case may be heard in the days leading up to the 2020 election, no opinion is expected to be issued until 2021.

Republicans largely approve (77%) of the Trump administration’s actions, while the vast majority of Democrats (91%) as well as more than half of independents (55%) disapprove of the Trump administration asking the Supreme Court to overturn the ACA.

If the Supreme Court sides with the Trump administration and the coalition of Republican attorneys general, all or parts of the 2010 Affordable Care Act would no longer be the law of the land. About half (53%) of the public do not want to see the ACA overturned by the Supreme Court while four in ten (38%) say they want to see the law overturned. Once again, attitudes are largely partisan with eight in ten Democrats (82%) and half of independents (51%) not wanting the law overturned, while seven in ten Republicans say the Supreme Court should overturn the 2010 health care law. Previous KFF polling has found that majorities across partisans want many of the ACA’s protections to remain in place.

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted July 14-19, 2020, among a nationally representative random digit dial telephone sample of 1,313 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). The sample included 292 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll at least nine months ago. Computer-assisted telephone interviews conducted by landline (323) and cell phone (990, including 714 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) as well as a subsample of respondents who are parents of children ages 5 to 17 who had previously completed interviews on the SSRS Omnibus and Sports polls (n=101). Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2018 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January-June 2019 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample, and design modifications, namely, the oversampling of prepaid cell phones and likelihood of non-response for the re-contacted sample. All statistical tests of significance account for the effect of weighting. The sample of parents with school-age children was weighted by: gender, age, educational attainment, race/ethnicity, and Census region.

The margin of sampling error including the design effect for the full sample is plus or minus 3 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. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

1. Due to sample size limitations, we analyzed parents who are Black, Hispanic, Asian, other races, or mixed race as a group (referred to as “parents of color”) compared to their White counterparts. We recognize these groups all have unique experiences; however, the sample size of the poll does not provide sufficient numbers of parents in each of these individual racial/ethnic groups to break out separately. ↩︎
2. States were categorized as coronavirus hotspots based on data available from KFF’s COVID-19 Metrics By States on July 20th, 2020 and qualified as a hotspot if cases had increased by 5% of more in the past 14 days and the positivity rate (14-day rolling average) was 10% or greater or if the positivity rate had increased by more than 1 percentage point in the past 14 days. ↩︎
3. Using the Cook Political Report’s 2020 Electoral College Ratings, the category of voters living in states and districts classified as “Toss-up”, “Lean Democrat”, and “Lean Republican” are analyzed as Electoral College voters. Voters in this category live in Michigan, Minnesota, Nebraska 2nd CD, New Hampshire, Pennsylvania, Wisconsin, Arizona, Florida, Georgia, Maine 2nd CD, North Carolina, Iowa, Ohio and Texas, constituting 195 volatile electoral votes.   ↩︎

The economic consequences of the coronavirus pandemic have led to historic levels of job loss in the United States and severe declines in state revenues. Medicaid is a countercyclical program, so during economic downturns more people lose income and will qualify for Medicaid at a time when it is difficult for states to support increased program spending. The Families First Coronavirus Response Act (FFCRA) provided a 6.2 percentage point increase in the federal share of Medicaid spending with requirements to maintain eligibility and provide continuous coverage for Medicaid enrollees. The FMAP increase included in the FFCRA was designed to provide broad fiscal relief to all states; however, the current level of aid may be small relative to state revenue losses and projected shortfalls, and the duration of the aid is not certain. It is likely that without an increase in federal support, states will need to make large budget cuts in many areas of the budget, including Medicaid, to meet balanced budget requirements. Without an extension in declaration of the public health emergency (PHE) set to expire at the end of July, the FMAP increase could end on September 30, 2020 (the end of federal fiscal year 2020 but partway through most state fiscal years), further deteriorating state finances.

This brief examines how much fiscal relief states can expect from the increase in the FMAP under FFCRA under different assumptions about the duration of the relief, how the FMAP increase provides broad fiscal relief to states and the factors that affect how much relief is available across states.

How much fiscal relief can states expect from the FMAP increase in FFCRA?

The Families First Coronavirus Response Act (FFCRA) included a temporary increase in the Medicaid FMAP from January 1, 2020 through duration of the emergency period. Federal fiscal relief provided through increases in the Medicaid FMAP—or the share of Medicaid costs paid by the federal government— during significant economic downturns has been successful in helping to support Medicaid and provide efficient and effective fiscal relief to states in the past. FFCRA uses this model as well. The 6.2 percentage point increase does not apply to the expansion group under the Affordable Care Act (ACA), for which the federal government already pays 90% of costs. To be eligible for the funds, states cannot implement more restrictive eligibility standards or higher premiums than those in place as of January 1, 2020, must provide continuous eligibility for enrollees through the end of the month of the emergency period, and cannot impose cost sharing for COVID-19 related testing and treatment services including vaccines, specialized equipment, or therapies. To access the enhanced funds, states submit claims for federal reimbursement for Medicaid expenditures. The purpose of the additional federal aid is not only to provide support to cover anticipated increases in enrollment, but also to provide broader fiscal relief for states.

The amount of federal relief to states is uncertain at this time because the duration of the FMAP increase is tied to the public health emergency (PHE). The current 6.2 percentage point increase in the match rate will expire at the end of the quarter in which the PHE ends. The current PHE is issued by the Secretary of HHS for 90 day periods. The PHE was first issued on January 31 and then renewed on April 26; it is set to expire on July 24. While it is expected that the PHE will be renewed again, if it were to expire in July, the increase in the match rate would expire on September 30, 2020. Under this scenario, states would receive an estimated $26.4 billion in relief (including an estimated $17.6 billion that may have gone out to states through June 2020, corresponding with the end of the 2020 fiscal year in most states). The amount of fiscal relief to states would grow if the increase in the match rate under FFCRA were in place longer. States could receive a total of $54.6 if the relief is in place through June 2021 (the end of state fiscal year 2021 for most states) and $64 billion if in place through September (the end of the federal fiscal year 2021) (Figure 1, Appendix Table 1).

An increase in the FMAP could offset or reduce state spending but is unlikely to fully offset state revenue declines and address budget shortfalls. An increase in the federal match rate would allow states to reduce state spending for Medicaid at the same amount as the increase in federal spending. Such a reduction in state Medicaid spending would relieve other budget pressures stemming from reduced revenues and other state spending increases. However, federal fiscal relief through Medicaid will not fully address state budget shortfalls.  Early estimates indicate that states are facing large shortfalls, with some estimates showing state budget shortfalls of $110 billion for SFY 2020 and $290 billion for SFY 2021. These shortfalls compare to an estimated $17.6B in federal fiscal relief in SFY2020 and $37.0B in SFY2021 (Exhibit 1) assuming the relief is in place through June 2021 and the increase in the FMAP at the current rate assuming the relief is in place through June 2021 (which is not certain). Other early reports from states similarly show state revenue declines of up to 15% in SFY 2020 and up to 20% for SFY 2021; compared to pre-pandemic state estimates of state revenue totaling $913B for SFY2020 and $944B in SFY2021, federal fiscal relief available through the FFCRA accounts for roughly 2% of state revenue in SFY2020 and 4% in SFY2021. Uncertainty about federal fiscal relief makes it difficult for states to budget and plan to meet balanced budget requirements. It is likely that the economic consequences of the pandemic will persist even beyond the public health crisis.

How does an FMAP increase provide state fiscal relief?

The FMAP increase included in the FFCRA was designed to provide broad fiscal relief to all states. Medicaid is a countercyclical program, so during economic downturns more people lose income and will qualify for Medicaid at a time when it is difficult for states to support increased program spending. Federal matching payments automatically increase as Medicaid spending grows, but state costs increase as well. The increase in federal support through a higher FMAP can help states maintain Medicaid coverage at a time when many people need it and can also help pay for costs for expected increases in enrollment. Because states make claims on federal Medicaid dollars throughout the year, and because Medicaid responds to economic conditions, increasing the FMAP provides relief funds to states using an existing mechanism and does not require development of new formulas to distribute grant funds, so funds can be distributed quickly. This can provide broad fiscal relief by freeing up funds for other purposes or filling gaps in overall state budget shortfalls.

Temporary FMAP increases to provide fiscal relief to states during economic downturns prior to the COVID-19 crisis allowed states to maintain Medicaid and address budget shortfalls. The enhanced match rate included in the American Recovery and Reinvestment Act (ARRA) provided states over $100 billion in additional federal funds during the Great Recession when the unemployment rate peaked at 10 percent in October 2009. As a result of this federal support, state spending for Medicaid declined by more than 10 percent in state fiscal year 2009, even with eligibility protections and increased enrollment (Figure 2). States reported that the relief was used to close Medicaid or other general fund budget shortfalls, support enrollment growth, and to mitigate or avoid provider and benefit restrictions.

What are other factors that affect the amount of fiscal relief available to states?

Expected increases in enrollment could offset a large share of the fiscal relief. States anticipate increased Medicaid enrollment due to the economic downturn, though it is unclear when enrollment will occur and what share of people will take up coverage. A survey of states found that nearly all states that had developed projections anticipate higher enrollment growth into FY 2021 as a result of the pandemic, and review of Medicaid managed care enrollment has shown early enrollment increases in many states, though enrollment is likely to grow over time. An earlier KFF analysis estimated potential loss of employer-based insurance (ESI) due to job losses from March 1 through May 2 and eligibility for ACA coverage among people losing ESI. It estimated by January 2021, when unemployment insurance (UI) benefits cease for most people, nearly 17 million people would be eligible for Medicaid, assuming those who are recently unemployed have not found work. The estimates do not account for participation rates among those newly eligible, those who may have lost jobs after May, individuals who do not lose job based coverage (i.e. those who may have had marketplace coverage) but experience income loss and become eligible for Medicaid, or the effect of the maintenance of eligibility (MOE) provisions that are in effect as a condition for states to receive the enhanced FMAP. The federal share for those newly eligible in the expansion group would be 90% (same as current law) while those newly eligible and enrolled in other categories would receive the regular lower match rate plus 6.2 percentage points, assuming the FMAP increase is still in place.

States have limited choices to cut Medicaid. As noted, to receive the increase in the FMAP under FFCRA, states cannot restrict eligibility and must provide continuous coverage for current enrollees. In prior economic downturns, states have turned to reductions in provider rates as well as cuts in some optional benefits. Often, these rates and benefits may be restored when economic conditions improve. States also frequently turn to greater reliance on provider taxes to help raise the state share of Medicaid during economic downturns. However, given that many providers, particularly those serving Medicaid enrollees, may be under fiscal strain from the pandemic, provider rate cuts may be harder to implement.

To save state dollars, states need to make larger program cuts to Medicaid. Because Medicaid is funded from a combination of federal and state funds, states need to make substantial cuts to Medicaid to generate state savings. For example, for a state with a 50 percent match rate, a $100 cut to Medicaid will reduce state spending by $50 and federal spending by $50. However, for the ACA expansion population, a $100 reduction will yield only $10 in state savings and reduce federal spending by $90 (as the federal match rate is set at 90 percent for newly eligible expansion adults).

The needs may vary across states. The pandemic may have different effects on economies and Medicaid enrollment across states. The current structure of the relief is broad and uniform across states and not tied to changes in unemployment or other economic conditions.

Looking Ahead

Without any additional changes in federal law, the amount of the fiscal relief from the FMAP increase without regard to enrollment changes will depend on the duration of the public health emergency. If the public health emergency is not renewed beyond the end of July, the FMAP increase will expire at the end of September, or the end of FY 2020. A July 10 letter from state groups again urged Congress to consider extending and increasing the FMAP increase (to 12 percentage points through September 2021) given overall state budget issues and increased demands for Medicaid. The House passed Health and Economic Recovery Omnibus Emergency Solutions Act (HEROES) included an additional increase in the FMAP of 14 percentage points from July 1, 2020 through June 30, 2021, but that proposal has not yet been considered in the Senate. Congress may consider a further increase in the FMAP during debate on additional legislation to address the pandemic, as well as options to target the fiscal relief to states experiencing the greatest need in terms of enrollment increases or increases in the unemployment rate.

Over the last month, many states have seen a surge of coronavirus cases, particularly in states that have loosened social distancing requirements. Data shows that younger people make up a growing percentage of new coronavirus cases in cities and states, and much recent media coverage has focused on the resurgence of the pandemic being driven by cases among younger adults. Less attention has been paid to recent trends in cases among residents and staff in long-term care facilities and how these relate to surges in “hotspot” states.

Coronavirus cases in long-term care facilities continue to rise. Over a 14-day period that ended on July 10^th, cases increased by 11% in long-term care facilities across the 35 states for which we were able to trend this data over this period (Table 1 and Figure 1). Long-term care facilities have implemented the strictest protocols in the country not only to prevent the virus from entering facilities, but also to prevent the spread of the virus once it is in the facility. Some of these policies include universal testing for residents and staff in long-term care facilities, strict visitor restrictions, and isolating positive-testing residents. Regardless of these measures, facilities continue to see a rise in cases. A rise in cases in long-term care facilities is particularly concerning, given that those who live in long-term care facilities are more vulnerable to severe illness and death from the virus than the general population.

Long-term care cases in “hotspot states” with wider community transmission have risen at four times the rate as long-term care cases in non-hotspot states. Long-term care facility cases in 23 hotspot states where data are available rose by 18% over a 14 day period (from 123,000 cases to 144,800 cases), while long-term care cases in 12 non-hotspot states rose by 4% over a similar 14-day period (from 125,500 cases to 130,300 cases). (Figure 1). These patterns indicate likely connection between widespread community transmission and long-term care cases, despite precautions in place in most long-term care facilities.

The two states with the highest overall increase in cases statewide, Texas and Florida, also report the highest increase in cases in long-term care facilities, with both states reporting an increase of approximately 50% in long-term care cases between June 24^th and July 9^th and nearly a doubling of cases during this time period (Table 1). These states, in particular, have garnered media attention, given the record-breaking numbers of new cases every day in these states. Experts have attributed these spikes to their quick pace of reopening, lack of social distancing measures such as face mask requirements, and increased population movement due to warmer weather. Increased cases in long-term care facilities may be attributed in part to increased testing of long-term care residents, but it likely represents a real increase in infections connected to the near doubling of all cases across the state in this 14-day period. The share of tests coming back positive in Texas and Florida are well over 10%, suggesting that community transmission is widespread and increasing.

Another factor that may contribute to continued long-term care case increases is resource shortages, with nearly 1 of 3 nursing homes reporting a staffing shortage, PPE shortage, or both. As of June 28^th, nearly 3,000 nursing homes across the country indicated a shortage of nursing staff, clinical staff, aides, or other staff. Nearly 2,700 nursing homes indicated a shortage of PPE supplies, which includes N95 masks, surgical masks, eye protection, gowns, gloves, and hand sanitizer. About 4,800 nursing homes (nearly 1 in 3 nursing homes) reported either a staffing shortage or a PPE shortage, indicating relatively widespread resource shortages. These shortages look similar between hotspot and non-hotspot states, with about 30% of nursing homes in each group of states reporting any shortages of staff or PPE (2,800 of 9,400 nursing homes in hotspot states and 1,000 of 3,300 nursing homes in non-hotspot states).¹ 

1. KFF analysis of CMS COVID-19 Nursing Home Data from June 28th. Data can accessed here: (https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/). ↩︎