The latest KFF poll finds most Americans (67%) think recent state-level abortion restrictions are designed to make access to abortion more difficult, rather than protect women’s health and safety. These state-level abortion restrictions have become more common in the last several years – with lawmakers arguing that these laws are intended to protect women’s health and safety.

Overall, twice as many think recent state actions are generally designed to make it more difficult for women to access abortion (67%) rather than protect the health and safety of women (32%). Three-fourths of Democrats (77%) as well as six in ten independents (61%) and Republicans (62%) say these state laws are designed to make it more difficult for women to access abortions. The poll also found the public overwhelmingly thinks that decisions about abortions should be made by women in consultation with their doctors (79%) rather than having lawmakers decide when abortions should be available and under what conditions (20%).

Despite knowing that these state actions are intended to reduce access to abortion, the poll also found that many support some of these regulations, including laws that require abortion providers to have admitting privileges at nearby hospitals (69%) and laws that prohibit abortions once cardiac activity is detected (49%).

However, opinions on many state-level abortion laws can change once people hear counter-arguments.   Support for admitting privilege requirements drops 17 percentage points to 52 percent after hearing that complications from abortions are extremely rare and women who need hospital treatment following a procedure can receive care whether or not the provider has admitting privileges. Support for fetal heartbeat laws drops 11 percentage points to 38 percent after hearing that cardiac activity is usually detectable around six weeks into pregnancy, before most women know they are pregnant.

Nearly five decades since the Supreme Court decision in Roe v. Wade, a majority (69%) of the public do not want to see the Supreme Court overturn the 1973 landmark case. While a majority of Republicans (57%) would like to see Roe overturned, larger majorities of Democrats (91%) and independents (70%) do not want it overturned.

Few (11%) think abortion should be illegal in all cases, with the remainder saying abortion should be legal in all cases (27%), legal in most cases (32%), or illegal in most cases (30%). Large majorities think abortion should be legal if the patient’s life is endangered (82%), in cases of rape or incest (80%), if the fetus is not expected to survive (75%), or if the fetus is expected to have serious birth defects (71%). A smaller majority say abortion should be legal for women who do not want to be pregnant (55%).

The poll also finds there are significant knowledge gaps on abortion among the public. A majority (69%) incorrectly think most abortions occur 8 weeks or later into a pregnancy and few (11%) are aware that less than 5% of abortions occur more than 20 weeks into a pregnancy.

In addition, only about one-fifth of adults (21%) and one-third of women between the ages of 18 and 49 (36%) have ever heard of Mifepristone, or a medication abortion.

Despite an increase in state-level abortion regulations and ongoing court cases regarding reproductive health care, these issues do not appear to be a priority in the 2020 election for most voters – even among Democrats. Health care generally is the top issue that Democrats want to hear discussed by the 2020 presidential candidates, with one-third calling it the most important issue. Only six percent of Democrats cite reproductive health issues, including birth control and abortion, as their chief concern.

METHODOLOGY

Designed and analyzed by public opinion researchers at KFF, the poll was conducted December 20-30, 2019 among a nationally representative probability-based sample of 1,215 adults including an oversample of 351 women, 18-49 years old. Interviews were conducted in English and Spanish online (1,100) and on the phone (115). The margin of sampling error is plus or minus 3 percentage points for the full sample and 6 percentage points for women, 18-49. See topline for margin of sampling error for other subgroups.

Medicaid, the provider of health insurance coverage for about one in five Americans and the largest payer for long-term care services in the community and nursing homes, continues to be a key part of health policy debates at the federal and state level. Key Medicaid issues to watch in 2020 include: Medicaid expansion developments; Section 1115 waiver activity; enrollment and spending trends; benefits, payment and delivery system reforms, and the implications of the 2020 elections.

Medicaid Expansion

At the start of 2020, 37 states had adopted the ACA Medicaid expansion. This total includes Idaho and Utah, which implemented the expansion on January 1, 2020, and Nebraska, where the expansion was adopted but not yet implemented. A review of over 300 studies points to positive effects of expansion on coverage, access to care, service utilization, and state budgets and economies. Millions of adults could gain Medicaid eligibility if additional states expanded their programs. Expansion activity is ongoing in a number of states that have not adopted the expansion. Initiatives are underway in Oklahoma and Missouri to put Medicaid expansion on the ballot in November 2020, while Kansas announced an agreement between the Governor and the Senate Majority Leader to adopt the Medicaid expansion in the 2020 legislative session. In addition, North Carolina came close to passing the Medicaid expansion through the state legislature during the 2019 session, but ultimately failed to do so, adjourning the session without a budget. Since the Governor continues to support expansion, the issue may come up again in 2020.

Some states are seeking waiver authority to implement a new expansion or make changes to an existing expansion. After Nebraska voters approved a Medicaid expansion ballot measure in November 2018, the state delayed implementation until October 1, 2020 to allow time for the state to seek a Section 1115 waiver to implement expansion. The waiver calls for a tiered benefit package; to access enhanced benefits, enrollees must meet certain wellness and personal responsibility requirements as well as work/community engagement requirements. Georgia submitted a waiver to the Centers for Medicare and Medicaid Services (CMS) seeking approval for a Medicaid expansion with enhanced ACA funding with coverage up to 100% of the federal poverty level (FPL) for individuals who meet work requirements. However, the state acknowledges recent CMS guidance indicating that the enhanced match rate will be available only to states that cover the entire adult expansion group (up to 138% FPL). The waiver proposal also contains other provisions that would restrict eligibility and benefits.

What to Watch:

• Will additional states move to adopt the Medicaid expansion in 2020?
• What strategies will states use to adopt the expansion (i.e., ballot initiative or state legislative process)?
• What restrictions will states impose through waivers (e.g., work or wellness requirements) as part of plans to expand Medicaid?

Medicaid Waivers

Section 1115 Medicaid demonstration waivers provide states an avenue to test new approaches in Medicaid not otherwise allowed under current law, provided the demonstrations meet the objectives of the program. The focus of Section 1115 waivers has changed over time reflecting changing priorities for states and CMS. Under the Trump Administration, CMS issued guidance for state Medicaid waiver proposals that would impose work requirements on individuals as a condition of Medicaid eligibility, and several states have received approval for or are pursuing these waivers. As of January 2020, seven states had approved waivers with work requirements, ten states had pending waivers and three other states (Arkansas, Kentucky and New Hampshire) have had waivers set aside by the courts, citing the Secretary’s failure to consider the impact on Medicaid’s primary objective of providing affordable coverage. Litigation challenging waiver approvals is pending in Indiana and Michigan, and an appeal of the court decision setting aside Arkansas’s waiver approval is also pending. The Kentucky waiver that had been set aside by the courts has since been rescinded by the new Governor, and the case has now been dismissed. Michigan is the only state currently implementing a work requirement waiver. Other states with approval have not yet implemented (Ohio, South Carolina, Utah, and Wisconsin) or have put the program on hold due to pending litigation (Arizona and Indiana). Data show that the majority of adult Medicaid enrollees are working and that prior implementation of a work requirement in Arkansas resulted in coverage losses for over 18,000 people without gains in employment.

Beyond work requirements, CMS has issued guidance and has been approving waivers to allow states to use Medicaid funds to provide short-term inpatient and residential treatment for enrollees with substance use disorder (SUD) and enrollees with serious mental illness (SMI) or serious emotional disturbance (SED) in institutions “institutions for mental disease” (IMDs). As of January 2020, 27 states have approval for such waivers for SUD services, and two states have approval for SMI/SED services. Without the waivers, states have limited authority to finance these services for nonelderly adults in IMDs.

While CMS has focused on increasing flexibility for states through waivers, some waiver requests have not been approved, including allowing for the ACA enhanced match for partial expansion (in Utah, Arkansas and Massachusetts), enrollment caps for the expansion group (in Utah) and closed prescription drug formularies (in Massachusetts). Some states continue to seek approval for similar waivers. CMS has been developing guidance and will consider a waiver from Tennessee seeking a modified block grant with shared savings provisions. New guidance on block grants and the outcome of the pending Tennessee waiver will have broader implications for other states interested in similar types of waivers.

What to Watch:

• How will the courts rule in the appeal of the Arkansas waiver related to work requirements and what will that mean for other states?
• Will CMS issue guidance about block grant waivers and will the pending Tennessee waiver be approved? How much flexibility will states be given under these block grant waivers?

Enrollment and Spending Trends

Medicaid spending and enrollment trends not only reflect policy changes at the state and federal level but also reflect changes in the economy as well as demographic changes. Over the last decade, Medicaid spending and enrollment peaked during the Great Recession (when incomes fell and more people qualified and enrolled in Medicaid and other public programs) and then again with implementation of the Affordable Care Act (ACA). Future Medicaid enrollment and spending trends will likely be affected by an inevitable economic downturn as well as the aging population.

In recent years, enrollment growth has slowed or declined in many states and declined nationally by 1.9 million from December 2017 through July 2019 as unemployment has reached historically low levels and the number of people in poverty has declined. While some enrollees leaving Medicaid may have gained other coverage, survey data show a rise in the uninsured rate between 2017 and 2018, suggesting that some individuals losing Medicaid are becoming uninsured. Some of this rise in the uninsured was among people with higher incomes, indicating that as people’s incomes rise due to the strong economy, they may not be transitioning to private coverage after losing Medicaid eligibility. A portion of Medicaid enrollment declines may reflect some states catching up on eligibility renewals after delays following implementation of new computer systems under the ACA. Experiences in some states suggest that some people who remain eligible may be losing coverage due to barriers maintaining Medicaid associated with renewal processes and periodic eligibility checks that have been encouraged by CMS as part of program integrity efforts. Other factors contributing to enrollment declines may be reduced funds to support outreach and enrollment assistance as well as the shifting immigration policy environment that may be deterring some families from enrolling themselves or their children in coverage or continuing coverage at renewal, despite being eligible.

While slower enrollment has moderated spending growth, rising costs for prescription drugs, provider rate increases, and costs for the elderly and people with disabilities (including increased utilization of long-term services and supports) are expected to put upward pressure on total Medicaid spending. In response to concern about the rising cost of new specialty prescription drugs as well as increasing costs for some generic drugs, states are continuing to adopt strategies to contain costs. Prescription drug efforts include addressing pharmacy benefit manager (PBM) spread pricing (the difference between the payment the PBM receives from the MCO and the reimbursement amount it pays to the pharmacy), negotiating additional supplemental rebates, and implementing new purchasing arrangements, including value-based contracts. Some states have more unique models, including a modified subscription model for hepatitis C drugs in Louisiana. CMS program integrity efforts including audits, heightened oversight of state claiming for enhanced federal matching funds for the ACA expansion and a new proposed rule related to supplemental payments and other state financing practices could have broader implications for Medicaid that could reduce federal spending in the program. In some cases, reduced federal spending may be tied to additional oversight to ensure states are complying with current rules, while in other cases the reductions may reflect CMS changes or proposed changes in policies.

Finally, Medicaid funding for the territories will continue to be an issue. As ACA funds and other disaster funds were set to expire Congress authorized additional funding of $5.7 billion for FY 2020 and FY 2021 (including $5.3 billion for Puerto Rico). However, the short extension and new disasters like the earthquakes in Puerto Rico mean that long-term funding is not secure and new health care needs will emerge.

What to Watch:

• Will Medicaid enrollment continue to decline?
• How will other CMS policy changes related to increased oversight, audits and policy changes affect Medicaid spending and enrollment?
• How will changes in Medicaid coverage affect the number of uninsured?
• What strategies will be successful in stemming cost increases for Medicaid prescription drugs while maintaining access to new medications?
• How will changes in the economy and the continued aging population affect Medicaid spending and enrollment trends in the future?

Benefits, Payment and Delivery System Reforms

Managed care continues to be the dominant delivery system for Medicaid. As of July 1, 2019, among the 40 states with comprehensive risk-based managed care organizations (MCOs), 33 states reported that 75% or more of their Medicaid beneficiaries were enrolled in MCOs. States continue to expand the scope of services included in MCO contracts by carving in behavioral health and long-term care services into MCO contracts. Nearly all states have managed care quality initiatives like pay for performance or capitation withholds in place, and many states are implementing alternative provider payment models (APMs) to incentivize quality and outcomes. In addition, both within managed care (often leveraging MCO contracts) and outside of managed care, states are experimenting with ways to address social determinants of health, though there are limitations in how far states can go in using federal dollars to pay for non-medical services. States are also working with their MCO and corrections partners to coordinate care for justice-involved individuals prior to release with the goal of improving continuity of care and smoothing community transitions. Many states are also implementing initiatives to improve birth outcomes and/or reduce maternal mortality. A number of states are also implementing payment policies to promote access to rural hospitals or other rural providers.

As the need for Medicaid long-term services and supports is expected to rise as the population continues to age, states continue to expand the number of people served in home and community-based settings; however, direct care workforce and affordable housing shortages remain challenges in meeting the demands to serve the elderly and people with disabilities in community settings. Existing authority to help states provide care in the community including spousal impoverishment rules and the Money Follows the Person program were set to expire at the end of 2019 but received an extension through May 2020.

Bolstered by a strong economy, an urgency to address the opioid and SUD crisis, and new options made available through the SUPPORT Act, many states are expanding Medicaid mental health/substance use disorder benefits, including medication-assisted treatment (MAT), and are using an array of pharmacy benefit management strategies to prevent opioid related harms. Funding through the new CMMI INCKids demonstrations was recently awarded to eight states to develop new delivery system and payment models focused on prevention, early identification, and treatment of children’s physical and behavioral health needs, including SUD.

What to Watch:

• How will states continue to use managed care to help advance quality and constrain costs? Will states increase oversight over managed care plans?
• How will states continue to leverage Medicaid to address key issues like maternal mortality, the opioid epidemic and other social determinants of health?
• How will states and the federal government develop capacity and meet workforce and housing challenges to meet the needs of the growing elderly population?

Implications of the 2020 Elections

Health care proved to be a dominant issue in the 2018 midterm elections and in some state elections in 2019. Once again, health care is a key issue for voters heading into the 2020 elections. Some Democratic presidential candidates support a Medicare-for-All option while others propose or endorse a “public option”. While there are differences across all of the proposals and many lack sufficient details to fully understand the effects, these plans all could fundamentally change the broader health care system and would have significant implications for Medicaid and the role of states, an issue that has not received much attention. Medicare-for-all proposals would shift responsibility for designing and implementing much of health policy from states to the federal government and would generally eliminate current variation in eligibility, enrollment and renewal processes, benefits, and payment and delivery systems that are part of the current structure of Medicaid where states have considerable flexibility to design programs. The proposals would extend coverage for certain Medicaid services such as comprehensive benefits for children and community based long-term care. Under some Medicare-for-all proposals, the federal government assumes all or a significant share state spending on Medicaid, leading to significant state savings, while other proposals call for a maintenance of effort for all or some current state Medicaid spending.

In contrast, public option proposals vary in their implications for Medicaid. Some proposals would have little effect on Medicaid while others would cover low-income adults in non-expansion states and/or allow individuals with Medicaid or private coverage to, instead, opt-in to the public option. Some proposals would allow states to move current Medicaid enrollees to the public plan and some would require states to contribute to the costs through an MOE.

All Democratic presidential candidates differ sharply from policies advanced by the Trump Administration related to the ACA and Medicaid more broadly. The Trump Administration has proposed to significantly limit federal Medicaid funds, convert Medicaid to a block grant, and repeal the ACA (which would end the authority for the Medicaid expansion and other Medicaid provisions); these policies are not supported by any Democratic candidate. In addition, litigation challenging the ACA with support from the Trump administration is ongoing, with continued uncertainty about the law’s future. On December 18, 2019, the 5^th Circuit decided in Texas v. Azar to send the case back to the trial court for additional analysis on whether the individual mandate can be severed from the rest of the ACA, to determine if the entire ACA is struck down or not. In the meantime, a group of 21 states represented by Democratic state officials and led by California, and the Democratic-led House of Representatives has asked the Supreme Court for an expedited review of the case, which could result in a final decision before the 2020 election.

In addition to the presidential race, the make-up of Congress will affect the direction of federal health care policy. At the state level, there are 11 governors up for election in 2020 (four seats currently held by Democrats (DE, NC, MY and WA) and seven seats held by Republicans (MO, ND, NH, IN, UT, VT and WV)). The make-up of state legislatures also has direct implications for Medicaid policy as state law can authorize expansion, require a state to submit a demonstration waiver, set state budgets and direct other Medicaid changes. As mentioned earlier, initiatives are underway in Oklahoma and Missouri to put Medicaid expansion on the ballot in November 2020.

What to watch:

• How prominent of a voting issue will health care be in the 2020 elections?
• What will be the outcome of the election – at the presidential level, as well as in Congress and the states – and how will this affect Medicaid and broader health policy in 2021 and beyond?
• How much of a role will Medicaid play in state races, particularly in non-expansion states? Will Medicaid expansion ballot initiatives pass in Oklahoma and Missouri?

Source

How Much Do Medicare Beneficiaries Spend Out of Pocket on Health Care?

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“How Has U.S. Spending on Healthcare Changed Over Time?” Peterson-KFF Health System Tracker

Source

Key Facts About the Uninsured Population

Key Points

• More than 3,300 cases, including more than 2,200 deaths, have been reported to date in the ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC), making it second only to the 2014-2015 West Africa outbreak that saw nearly 29,000 cases and claimed more than 11,300 lives. The outbreak has lasted a year and a half already, having been first declared by the DRC Ministry of Health on August 1, 2018. There are ongoing concerns about cross-border spread outside the DRC.
• Since July 2019, the outbreak has been considered a “public health emergency of international concern” (PHEIC) by WHO.
• Although the DRC has a history of successfully containing Ebola outbreaks and responders have access to new prevention tools such as an Ebola vaccine, multiple factors have impeded the response in the affected areas this time including violence and insecurity, community mistrust of government and external responders, funding constraints, and a complex political and socioeconomic operating environment.
• U.S. engagement has been limited compared to the 2014-2015 West Africa outbreak where the U.S. played a leading role and mobilized an unprecedented amount of funding, and personnel. In contrast, the U.S. has chosen to play a more limited role in this outbreak due partly to concerns about security, which have led the U.S. to restrict its personnel from working in the outbreak zone. Even so, the U.S. is the largest single international donor to the Ebola response effort in the DRC.
• The U.S. Agency for International Development (USAID) and the U.S. Centers for Disease Control and Prevention (CDC), along with several other U.S. agencies, have provided technical and financial support to international response efforts in the DRC. A USAID Disaster Assistance Response Team (DART), which includes USAID and CDC staff, has been deployed to the DRC since September 2018.
• Policy questions for the U.S. government going forward include whether it will change its approach in order to allow government personnel to engage directly in frontline response activities and how it will support the transition from emergency response to longer-term support for improving health care in the affected areas.

Current Situation

When did the outbreak begin, and what countries are affected?

The current Ebola outbreak was first declared by the DRC Ministry of Health on August 1, 2018 (see timeline of key events below). Almost all cases of Ebola in this outbreak so far have occurred in the two northeastern DRC provinces of Ituri and North Kivu, though a few cases have recently been identified in South Kivu province. This outbreak is the tenth – and by far the largest – in the DRC’s history and the second largest Ebola outbreak ever recorded after the West Africa Ebola outbreak in 2014-2015 that saw 28,616 cases, including 11,310 deaths, in the three most affected countries (Guinea, Liberia, and Sierra Leone).

Cross-border spread remains a concern. Uganda has reported several imported Ebola cases in areas bordering the DRC, with the most recent reported on August 26, 2019. WHO says there is a risk of further spread within the DRC and potentially across borders to Burundi, Rwanda, South Sudan, and Uganda, in particular. Several cases over the summer of 2019 in the large city of Goma, a regional and international transport hub that directly borders Rwanda, highlighted such concerns. Given the risks, neighboring countries have been preparing for possible cases for some time.

How many cases and deaths have there been in the DRC?

As of December 16, 2019, the DRC Ministry of Health reports the country has had 3,348 cases (see figure below), of which there were 2,210 deaths. The number of new cases reported each week has declined noticeably since the end of July 2019, indicating progress has been made in interrupting transmission. Still, cases continue to occur, and recent violence in some Ebola-affected areas has interrupted the response, sparking concerns about this potentially leading to an increase in Ebola cases. Regardless, response activities could be needed for another several months at least, and another increase in transmission remains a concern. The crude case fatality ratio for this outbreak is high, at 66%, as of December 16, 2019.

Health care workers (HCWs), such as nurses and doctors, caring for Ebola patients have been at particularly high risk of infection. At least 169 cases (about 5% of total cases) over the course of this outbreak have occurred among HCWs. This Ebola outbreak has also disproportionately affected children, with about 15 percent of all cases occurring among children under 5 and a higher proportion of the child cases dying from the disease compared with older age groups.

What are the key factors driving the outbreak in the DRC?

Multiple issues make responding to this Ebola outbreak more challenging than any prior outbreaks in the DRC. These include:

• ongoing violence from armed groups that is impeding the response efforts, including violence against Ebola responders, amid long-standing conflict;
• mistrust of the DRC government and outsiders, including Ebola responders, in affected communities;
• disbelief in Ebola (studies find that many in the affected areas believe the Ebola outbreak is not real but rather a hoax perpetrated by the government or other outside parties);
• a shortfall in funding for the Ebola response efforts in the DRC, despite increasing calls from the World Health Organization for donors to fill the gap; and
• transitions in the leadership of the DRC government, including transitions in oversight of the Ebola response.

This combination of factors has made responding to this outbreak a much more difficult challenge compared with previous outbreaks in the DRC (see KFF brief).

Role of the U.S.

U.S. engagement in the current outbreak has been limited compared to its role in the 2014-2015 West Africa Ebola outbreak response, where the U.S. played a major leadership role, mobilizing an unprecedented amount of funding, other resources, and personnel to support the Ebola response. Since then, there have been improvements in the global capacity to respond to Ebola, particularly on the part of WHO, and the DRC has had significant experience in addressing prior Ebola outbreaks; both WHO and the DRC took the lead early on in the current outbreak (see KFF brief). In addition, insecurity in the affected areas of the DRC has prevented U.S. agencies from being more involved, as U.S. personnel have been mostly restricted from working directly in the hardest hit areas due to safety concerns. However, the U.S. has provided significant funding and technical assistance in the DRC and in neighboring countries, working in conjunction with national governments, United Nations (U.N.) agencies, and other organizations leading the response. In fact, the U.S. is the largest donor to the Ebola response effort in the country, having provided over $250 million since August 2018.

While the number of Ebola cases in the DRC continues to decline from a peak over the summer, major challenges remain for the U.S. and other responders, such as: completing the task of interrupting transmission even amid ongoing violence, preventing expansion of the outbreak into other geographic areas, and effectively transitioning from an emergency response to a longer-term development effort to help stabilize and build up health systems in the affected areas.

What U.S. agencies are involved in the response?

The U.S. Agency for International Development (USAID) and U.S. Centers for Disease Control and Prevention (CDC) are the two main agencies contributing to the U.S. government response. USAID’s Office of Foreign Disaster Assistance (OFDA) coordinates U.S. emergency response efforts in the DRC, and in September 2018, the agency deployed a Disaster Assistance Response Team (DART) to the DRC in response to the outbreak. USAID’s Bureau for Global Health provides operational and personnel support. Several CDC offices, including the Center for Global Health’s Division of Global Health Protection and the National Center for Emerging and Zoonotic Infectious Diseases’ Division of High-Consequence Pathogens and Pathology (NCEZID/DHCPP), provide technical and personnel support. CDC efforts in the DRC are coordinated through its Emergency Operations Center (EOC) in Atlanta, which was activated in June 2019 at its lowest level (level 3).

Other U.S. agencies engaged in Ebola efforts include the National Institutes of Health (NIH) (conducting research on drug and vaccine development, including Ebola treatment trials in the DRC); the U.S. Food and Drug Administration (FDA) (regulating drug and vaccine development); and the Department of State (coordinating the U.S. and international diplomatic response).

Are U.S. government personnel working in the outbreak areas in the DRC?

U.S. personnel have been assisting in the DRC since the outbreak was announced in August 2018, but since late August/early September 2018, no U.S. personnel have been allowed to directly engage in response activities in active transmission areas in northeastern DRC. Citing safety concerns due to ongoing violence there, U.S. officials have decided to keep CDC and other U.S. staff away from the front lines of the response. Outside experts have made calls for the U.S. to return CDC staff to affected areas to assist more directly. So far though, there is little indication that the U.S. government will deviate from its current policy, though CDC reports working with the U.S. Department of State to “pre-position CDC staff in Goma to rapidly respond to hotspots where the security situation is permissible.”

Outside of the outbreak zone, U.S. personnel continue to assist. The DART – a “team of disaster and health experts” from USAID and CDC – continues its work in the DRC in response to the outbreak. CDC reports 34 staff working the DRC. Other CDC workers have deployed to WHO headquarters and to neighboring countries, such as Uganda, to assist in keeping the virus from crossing borders and to support countries in preparedness and response activities.

How much funding has the U.S. provided?

USAID reports providing about $266 million toward the Ebola response in the DRC and surrounding countries since the outbreak began in August 2018. Of this amount, $252 million is for activities in the DRC, while $14 million is for preparedness and response activities in Burundi, Rwanda, South Sudan, and Uganda. No estimate is available for the amount that CDC has spent on its Ebola response activities, though WHO reports the CDC has provided $500 thousand in funding to its efforts. The funding for both USAID and CDC, as well as for other U.S. agencies, in the response is not new funding; rather, it has been drawn from unspent FY 2015 emergency Ebola supplemental appropriations provided by Congress at the time of the West Africa Ebola outbreak. For USAID, leftover funding in the International Disaster Assistance (IDA) account that was designated for “assistance for countries affected by, or at risk of being affected by,” Ebola is being utilized for this purpose, and for CDC, leftover funding that was designated for Ebola international preparedness and response is being utilized. CDC’s leftover funding expired at the end of FY 2019 on Sept. 30, 2019 and, per communication with CDC, was expected to have been entirely spent by that time. In recent months, Congress has stated that CDC may use existing funds in the Infectious Diseases Rapid Response Reserve Fund, which was established in FY 2019, for CDC Ebola response.

Global Response Activities

Who leads the response to the outbreak?

The DRC government, including the Ministry of Health, and agencies of the U.N. lead the outbreak response. WHO is the lead U.N. agency for the public health response; other key U.N. actors include the U.N. Office for Coordination of Humanitarian Affairs (OCHA), the U.N. Children’s Fund (UNICEF), the World Food Programme (WFP), and MONUSCO, a multinational peacekeeping force that has been assisting with security. U.N. actors are led by a U.N. Emergency Ebola Response Coordinator.

Other key actors in and supporters of the response include governments of various countries, including the U.S.; multilateral organizations, such as the World Bank and Gavi; international and national non-governmental organizations (NGOs), such as Medicins Sans Frontieres (MSF), International Medical Corps, the Alliance for International Medical Action (ALIMA), and the International Red Cross/Red Crescent; and other partners.

What is the plan for ending the outbreak in the DRC?

Current public health response efforts in the DRC are focused on interrupting chains of Ebola transmission through identifying, isolating, and caring for cases before they transmit the disease further. The goal of the response is to bring the number of cases down “to zero”. Ebola outbreaks are usually declared to be over after 42 days have passed since the last known case (equal to two incubation periods of Ebola virus disease). A national Strategic Response Plan outlines the overall strategy, objectives, and priority activities for responding to the outbreak. There have been four iterations of the plan to date, each covering a specific period of time. The current plan that focuses on the core public health “pillar” of the response covers planned activities from July through the end of December 2019. It addresses strengthening response capacities in priority areas such as: coordination, surveillance and laboratory capabilities, infection prevention and control measures, vaccination, human resources, security, and risk communication among others. Complementary humanitarian response activities are another “pillar” of the response and outlined in a broader integrated Ebola response strategy, which includes efforts addressing food assistance, employment, and economic development in Ebola-affected regions.

Has the outbreak been declared a global emergency?

On July 17, 2019, the WHO Director-General accepted the recommendation of the Emergency Committee and declared the DRC Ebola outbreak to be a “public health emergency of international concern” (PHEIC). A PHEIC is “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.” In its declaration, WHO released a set of recommend actions for affected countries, neighboring countries, and all states. This was the fourth time the Emergency Committee had met to discuss a potential PHEIC declaration for Ebola in the DRC; each of the prior three times the Committee recommended not to do so.

At its most recent meeting, on October 17, 2019, the WHO Emergency Committee again recommended that the PHEIC declaration remain in place.

What has been the role of vaccination in the current outbreak?

Vaccination has been an important component of the response since it began. This outbreak marks the first time that an effective vaccine is available and being used as a core component of an Ebola response. Authorities have mostly used a “ring vaccination” approach, targeting vaccination of those who have been in contact with a case of Ebola and the contacts of those contacts, as well as other groups at potential risk of exposure such as health care workers. As of December 8, 2019, over 256,000 people have been vaccinated in the DRC since the start of the outbreak, which has likely prevented hundreds, if not thousands, of Ebola cases already. Authorities have been primarily using a vaccine manufactured by Merck, which the company has provided free of charge to WHO and the DRC for the purposes of the response. The Merck vaccine, which was being deployed on an emergency use basis under a “compassionate use” protocol, received approval from European regulators and prequalification from WHO in November 2019, making it the first officially licensed Ebola vaccine. It is not yet approved and licensed by the FDA (though it is under review and an FDA regulatory decision is expected in early 2020). Costs for vaccine distribution and management of vaccinations in the response are shared among Gavi, WHO, other donors, and the DRC government.

In addition to the vaccination efforts in the DRC, neighboring countries are also vaccinating certain people, such as health workers, in areas at risk of seeing or that have seen Ebola cases due to cross-border spread (like Uganda, with at least 5,000 people vaccinated thus far).

A second Ebola vaccine, manufactured by Johnson & Johnson, is also available. Following recommendations from WHO and other expert groups, the DRC government decided to introduce the second vaccine into some at-risk areas of the country that do not have active Ebola transmission. For example, DRC authorities began vaccinating 50,000 people in Goma with the second vaccine in November 2019, and in December 2019, the DRC and neighboring Rwanda initiated a new vaccination campaign using that vaccine to protect people in at-risk areas on their mutual border.

Is there an adequate supply of vaccine?

It appears there are enough doses of the Merck vaccine to meet the demands of the current WHO/DRC government’s ring vaccination approach. Currently there are enough vaccine doses to vaccinate 300,000 people, which is greater than the total number of people vaccinated in the outbreak over the first 17 months of the response. In addition, WHO reports that Merck will produce enough vaccine over the next 6 to 18 months to vaccinate an additional 1.3 million people. Gavi announced in December 2019 that it will support a new global stockpile of 500,000 doses of Ebola vaccine, to be made available for emergency use as needed.

There is reportedly an adequate supply of the second (Johnson & Johnson) Ebola vaccine, with enough to vaccinate approximately 2 million people.

Are treatments available for those infected with Ebola?

There are no FDA- or other approved treatments for Ebola, though several promising treatments are under development. Four experimental treatments have been studied in a clinical trial among Ebola patients in the DRC, and in August, the U.S. NIH announced that initial results of the trial indicated two of those treatments (the monoclonal antibody mAb114 and the multi-antibody “cocktail” REGN-EB3) showed the most promise. Ebola patients in the DRC enrolled in the trials are offered these two treatments as investigators further evaluate them. The treatments are still under investigation and being offered on a “compassionate use” basis only in the DRC.

What has the response cost, and how much funding has been provided?

From August 2018 through early December 2019 the amount of funding directed to response activities in the DRC included under four iterations of a national Strategic Response Plan has reached $361 million. This amount does not include additional DRC outbreak activities not captured under the plans, nor response costs in Uganda and preparedness costs in neighboring countries.

Funding amounts provided under each of the plans so far:

• August – October 2018: DRC government data show that the first plan was fully funded, with $44.2 million made available to meet the $43.8 million requested for the August to October 2018 period the plan covered.
• November 2018 – January 2019: U.N. data shows that the second plan was fully funded, with donors (largely the World Bank) providing $61.4 million (including some funds leftover from the first phase of the response) of the $61.3 million requested to cover the period through January 2019.
• February – July 2019: U.N. data shows the third plan has received $109.3 million from February through July 2019, of the $147.9 million requested to cover the period through July 2019. This includes $40 million from the World Bank, with more promised, and $31.2 million from USAID.
• July – December 2019: WHO data shows the current plan has received at least $148.3 million from August through early December 2019, of the $287.6 million requested for the public health pillar of the response through December (U.N. data tracking donor funding toward the current plan is not yet available, but WHO is reporting the funding it has received under the plan). The plan has substantially higher funding needs than prior iterations. The broader response strategy, which includes the funding requirements of the public health pillar within its funding assessment, is requesting more than $500 million for the broader DRC response through December; some donors, including the World Bank, United Kingdom, and the European Union, have already announced they will be providing additional funding for the response.

As mentioned earlier, USAID reports providing about $252 million toward the Ebola response in the DRC and about $14 million for activities in neighboring countries since the outbreak began in August 2018 (this includes funding channeled through the DRC national plans as well as funding not captured under the plans). No estimate is available for the amount that CDC has spent on its Ebola response activities, though WHO reports the CDC has provided $500 thousand in funding to its efforts. All U.S. funding for the current outbreak is drawn from existing funding sources (i.e., no new funding has been appropriated to agencies by Congress for this Ebola response, thus far).

See the KFF data note on donor funding for the response for further information.

Key Issues Going Forward

Now well into its second year, the Ebola outbreak in the DRC remains challenging for responders, despite having important tools (such as vaccines and new treatment options) on hand. This is because the underlying factors driving transmission of Ebola in the DRC remain. The security situation shows no sign of abating, and there is a fear that it can always worsen. Mistrust of public health authorities also remains a barrier to response efforts. While it is not possible to predict the trajectory of the outbreak, it could take at least a few more months to fully contain even under good circumstances, so given the complex set of challenges being faced, the outbreak could take even longer than that to be brought under control.

Addressing these longstanding challenges more effectively is the aim of the broader integrated response strategy being implemented in the DRC. This strategy, which includes the public health pillar’s current national plan and is designed to guide the response through the end of December 2019, calls for greater community engagement, support for health and development interventions beyond addressing Ebola alone, a new approach to security, and more coordination among all responders.

Finally, the major questions for the U.S. government going forward include: whether or not it will change its approach and engagement in the DRC to allow U.S. government personnel to directly engage in public health activities on the frontlines of the response, how the U.S. will contribute to finally breaking all chains of transmission, and how the U.S. will support efforts to transition from an emergency response to a longer-term strategy for supporting the health care system in the affected areas to help prevent and contain any future recurrences of Ebola or other outbreaks.

Additional Resources

• DRC Ministry of Health – WHO AFRO Ebola in DRC dashboard
• DRC Multisectoral Committee on Ebola Response (CMRE) daily situation reports (from Aug. 3, 2019)
• DRC Ministry of Health daily situation reports (prior to Aug. 3, 2019)
• WHO DRC Ebola situation reports (earlier reports)
• WHO Ebola disease outbreak news
• USAID DRC Crisis webpage
• CDC Ebola Outbreak in the DRC webpage
• KFF infographic Ebola: 5 Key Questions
• KFF Ebola materials

Key Points

• The ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC) has required increasing amounts of external support from donors (for more information on the outbreak, see KFF’s explainer). Yet there has been limited information about donor funding to date and a lack of a centralized reporting mechanism for tracking funding.
• This analysis provides an updated overview of donor funding for the DRC Ebola response by source. Highlights include:
  • We estimate that from August 2018, when the outbreak began, through early December 2019, approximately $734 million was provided by donors to address Ebola in the DRC.
  • More than half (57.8%) was provided by donor governments bilaterally, including the U.S., with a large share (40.1%) provided by multilateral and international organizations and a small proportion (2.2%) provided by non-profits, such as private foundations.
  • The U.S. provided the largest amount of support ($252 million), followed by the World Bank ($170 million), the United Kingdom ($78 million), the World Health Organization (WHO) Contingency Fund for Emergencies ($73 million), and the European Union ($52 million).
  • About half of funding (49%), including about a fifth of U.S. funding, was provided in direct support of the official DRC response plans, which guide national response strategy and enumerate resource needs. This could have implications for the coordination of donor efforts and whether funding is being directed to the most critical or pressing activities.
  • There is also considerable uncertainty about the future of U.S. support since it is unclear how much funding remains available for use in the response, whether the current administration will request additional funds, and whether Congress will provide such funding.

Donor Funding for the DRC Response

Based on analysis of publicly available information, we estimate that donors provided approximately $734 million in overall financial support for the DRC Ebola response from August 2018, when the outbreak began, through early December 2019 (see Table 1). We attributed funding to donor governments for Ebola when designated for this purpose, whether provided bilaterally to the DRC or earmarked for Ebola but provided to a multilateral organization or instrument. We attributed funding to a multilateral organization where that multilateral organization specifically designated general funds for this purpose. Data sources are provided in Table 1.

More than half (57.8%) of this funding was provided by donor governments bilaterally, including the U.S., with large share (40.1%) provided by multilateral and international organizations, such as the World Bank, and a small proportion (2.2%) provided by non-profits, such as private foundations.

The U.S. government was the largest donor, having provided $252.4 million for activities within the DRC (see Figure 1 and Box 1), followed by the World Bank ($170 million), the United Kingdom ($78.4 million), the WHO Contingency Fund for Emergencies ($73.1 million), and the European Union ($52.4 million).

Funding for National Response Plans

The DRC government, U.N. agencies such as WHO, and other partners prepared four DRC national Strategic Response Plans (“the plans”) to guide and enumerate resource needs for the Ebola response (see Table 2). We found that about half (49%, $361 million) of donor funding for the response – including about a fifth (19%, $47.9 million) of U.S. funding – was identified as directly supporting the national plans.

Donors met the funding requests in the first two plans and mostly met that of the third plan. As of early December, they have provided at least $148.3 million (via WHO) toward the fourth plan, which requests $287.6 million for public health response activities from July through December 2019.

Authorities in the DRC have also requested an additional $225.6 million for July through December 2019 under a broader strategy that includes other activities, such as economic development, to address social conditions that drive the outbreak. In support of this broader strategy, some donors have pledged more funding. The World Bank, for example, pledged up to an additional $300 million ($70 million of which has already been provided), and the United Kingdom pledged up to an additional $62.6 million, or £50 million ($9.7 million, or £8 million, of this funding has already been provided for preparedness efforts in neighboring countries, and $23.8 million of this funding has already been provided to WHO). More recently, the European Union has pledged an additional $54.7 million (€50 million) in support of the broader response.

Key Issues for the U.S. and Other Stakeholders

Maintaining a robust response to Ebola in the DRC over the next several months, and maybe even longer, will require additional donor funding. As such, there are several issues for the U.S. and other donors to consider:

• Overall, information on donor financing is limited and fragmented. No systematic resource or tool for tracking contributions exists, a situation made more complex because the Ebola response is taking place in the context of a broad set of humanitarian crises with multiple multilateral and bilateral funding mechanisms contributing resources across a spectrum of activities (see KFF explainer). For the U.S. specifically, while some data are available, the full range of funding information has not been provided.
• Coordination of donor funding outside official national response plans is unclear. With about half of donor funding for the response – including about a fifth of U.S. financial support – identifiable as directly supporting the official national response plans, it is not clear whether donor efforts are being coordinated effectively and funding provided for the most critical or pressing activities, including those identified under the official national response plans. With regard to the U.S. specifically, there is limited information about how U.S. funding and efforts are coordinated with U.N. and DRC-led efforts.
• The status of U.S. funding going forward is uncertain. It is unclear how much funding remains available for use in the U.S. response, whether the current administration will request additional funds, and whether Congress will provide such funding. At USAID, it is unclear what funds remain in the leftover FY 2015 emergency Ebola funding being used for response activities. At CDC, all leftover FY 2015 emergency Ebola funding was to be spent out entirely by the end of FY 2019, but the agency may use funds from the emergency reserve fund for its Ebola activities in FY 2020 (see Box 1).

The FY 2020 appropriations conference agreement, released by Congress on December 16, 2019 and passed by both the House (12/17) and the Senate (12/19), includes funding for U.S. global health programs at the State Department, the U.S. Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH). The agreement still needs to be signed by the President. Key highlights are as follows (see table for additional detail):

State Department & USAID:

• Funding for global health programs, through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totaled $9.1 billion, an increase of $255 million above the FY 2019 enacted level, and $2.7 billion above the President’s FY 2020 request.
• Bilateral HIV funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) is $4,700 million, flat compared to the FY19 enacted level, but $1,350 million above the FY20 Request ($3,350 million).
• The bill includes $1,560 million as the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), an increase of $210 million above the FY19 enacted level ($1,350 million) and $602 million above the FY20 Request ($958 million). The bill states that this amount is for the first installment of the sixth replenishment. In addition, the explanatory statement accompanying the bill reaffirms the U.S. share of 33% of contributions.
• Funding for tuberculosis (TB) totals $310 million, $8 million above the FY19 enacted level, and $49 million above the FY20 Request ($261 million).
• Funding for malaria totals $770 million, $15 million above the FY19 enacted level ($755 million), and $96 million above the FY20 Request ($674 million).
• The bill includes $851 million for maternal and child health (MCH), an increase of $16 million above the FY19 enacted level ($835 million), and $231 million above the FY20 Request ($629 million). Specific areas under MCH include:
  • Gavi, the Vaccine Alliance funding totals $290 million, matching the FY19 enacted level, and $40 million above the FY20 Request ($250 million).
  • Polio funding through all accounts totals $61 million, $2 million above the FY19 enacted level ($59 million), and $38 million above the President’s FY 2020 Request.
  • The bill includes $139.0 million for the U.S. contribution to the United Nations Children’s Fund (UNICEF) provided through the International Organizations and Programs (IO&P) account, $1.5 million above the FY19 enacted level ($137.5 million). While the FY20 Request did not specify a funding amount for UNICEF and proposed to eliminate the IO&P account, it is possible that organizations such as UNICEF could receive funding through other accounts.
• Funding for nutrition totals $150 million, $5 million above the FY19 enacted level ($145 million), and $71 million above the FY20 Request ($79 million).
• Bilateral family planning and reproductive health (FP/RH) funding totals $575 million ($524 million through the GHP account and $51 million through the ESF account), matching the FY19 enacted level, and $316 million above the FY20 Request ($259 million).
• Funding for the United Nations Population Fund (UNFPA) totals $32.5 million, matching the FY19 enacted level; the FY20 Request proposed eliminating funding for UNFPA.
• Funding for the vulnerable children program totals $25 million, $1 million above the FY19 enacted level ($24 million); the FY20 Request proposed eliminating funding for this program.
• Funding for neglected tropical diseases (NTDs) totals $102.5 million, matching the FY19 enacted level, and $27.5 million above the FY20 Request ($75 million).
• Funding for global health security (GHS) totals $100 million in the bill. While this is a decrease compared to the FY19 enacted level ($138 million), $38 million of the FY19 amount was provided through a one-time transfer of unspent emergency Ebola funding. The FY20 conference agreement amount is a $10 million increase compared to the FY20 Request ($90 million).

Centers for Disease Control and Prevention (CDC): Funding for global health provided to the CDC totals $571 million, an increase of $75 million compared to the FY19 enacted level ($496 million) and $114 million above the FY20 Request ($457 million). The entire increase in CDC funding is to support global health security activities.

Fogarty International Center (FIC): Funding for the Fogarty International Center (FIC) at the National Institutes of Health (NIH) totaled $81 million, $3 million above the FY 2019 enacted level ($78 million) and $14 million above the FY20 Request.

Additional Global Health Legislation: The appropriations bill also included the “End Neglected Tropical Diseases Act” as well as the “Preventing Child Marriage in Displaced Populations Act.” Learn more about these two bills on the KFF U.S. Global Health Legislation Tracker here.

Additional Resources:

• “Further Consolidated Appropriations Act, 2020” – Bill Text
• FY2020 State and Foreign Operations Appropriations – Explanatory Statement
• FY2020 Labor, HHS – Explanatory Statement

The table below compares global health funding in the FY 2020 conference agreement to the FY 2019 enacted funding amounts as outlined in the “Consolidated Appropriations Act, 2019” (P.L. 116-6; KFF summary here), the President’s FY 2020 request (KFF summary here).