Potential Health Policy Administrative Actions in the Second Trump Administration

President-elect Trump could exercise executive branch authority through administrative action to quickly move forward on some policy changes without congressional action.

Published: Dec 16, 2024

This is a quick guide to potential health policy administrative actions under the incoming Trump administration based on campaign positions and statements by President-elect Trump, President Trump’s record during his first administration, and expected actions that would reverse or modify regulations or guidance issued by the Biden administration. Click the + to expand for details of each potential action.

Note: This is not an exhaustive list of possible administrative actions by President-elect Trump and the guide may be updated as new information becomes available up until his inauguration on January 20, 2025.

Affordable Care Act

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Abortion

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Medicaid

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Immigration and Health

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LGBTQ Health Policy

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Public Health

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Racial Health Equity and DEI Initiatives

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Prescription Drugs

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Fentanyl

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Water Fluoridation in the U.S.: The Federal Role in Policy and Practice

Published: Dec 13, 2024

Introduction

Fluoridating water has been a long-standing public health practice in most communities across the U.S. and has been supported and recommended by the federal government for decades. Even so, ever since the first U.S. community began fluoridating its water in 1945 there have also been concerns raised about this practice and many communities choose not to fluoridate. In recent years, in fact, there has been growing scrutiny of the practice, and debates in many parts of the country about whether to continue fluoridation. President-elect Trump’s announced nomination of Robert F. Kennedy Jr. to be the Secretary of Health and Human Services has raised questions about the potential for the federal government to influence water fluoridation practices across the country. Kennedy has long been critical of water fluoridation and has said the incoming Trump administration will recommend that fluoride be removed from public water on day one. Meanwhile, key professional associations, public health experts, and many policymakers continue to support fluoridation as an important tool for improving dental health in the U.S., and perhaps one of the most important public health interventions ever implemented.

To help inform policy discussions about this topic, this brief provides an overview of the role of the federal government in water fluoridation decisions and the current status of water fluoridation in the U.S. While the federal government cannot require communities to fluoridate their water or remove fluoridation already in place, it does regulate maximum levels and provides guidance to state and local communities on optimal levels of fluoride. If guidance were to change – for example, suggesting that fluoride was not recommended — it could have ripple effects across the country.

The Federal Government’s Role and Current Recommendations for Water Fluoridation

The federal government does not have legal authority to require state and local communities to fluoridate their water, nor to remove fluoridation in areas where it is already policy. Instead, these decisions – just like many public health policy decisions in the U.S. – are made at the state and local levels. There are some states (for example: California, Delaware, Georgia, Illinois, Kentucky, Louisiana, Minnesota, Mississippi, Nebraska, Nevada, Ohio and South Dakota) that require water systems of a certain size within their state to provide fluoridated water, while others leave this decision to city, county, or other officials or leave the choice up to voters who decide via local referendums. At the same time, the federal government – specifically the Environmental Protection Agency (EPA) – does have the primary authority to set and regulate the maximum level of fluoridation in public water systems.

The federal government reviews data and other evidence about the safety and effectiveness of fluoridation and issues recommendations and guidance on best practices for state and local decision-makers to consider. The Department of Health and Human Services (HHS), in particular the Centers for Disease Control and Prevention (CDC), provides recommendations about best practices for achieving public health benefits from fluoridation. The first federal guidelines regarding fluoridation of water systems came from the U.S. Public Health Service (USPHS) in 1945, with a recommended maximum concentration level. Updated guidelines in 1962 revised this maximum, and included, for the first time, a recommended fluoride level, citing its ability to prevent dental caries; the most recent update to these federal guidelines was in 2015.

The federal government also sets and enforces nationwide standards for maximum allowable fluoridation levels. The EPA, acting via the authority provided through the Safe Drinking Water Act of 1974, is responsible for setting federal standards for maximum fluoridation levels in water systems to protect against risks from excessive exposure to fluoride. This includes setting a primary, legally enforceable standard for water fluoridation levels, and a secondary “non-enforceable” standard. If a water system’s fluoridation levels exceed the primary enforceable standard, legal action can be taken against the water provider; if levels exceed the secondary, non-enforceable standard, it does not trigger legal or federal action, but public notice of the exceedance must be provided to persons served by the system no later than 12 months after the levels were exceeded. EPA delegates this regulatory and enforcement authority to states that meet certain capacity requirements. States may also set their own maximum fluoride levels, as long as they are at least as stringent as federal standards.

Current HHS/USPHS guidelines (last updated in 2015) recommend an optimal fluoride concentration of 0.7 mg per liter (mg/L) in community water systems (CWS) while EPA regulations set the primary standard for the maximum level of fluoride in water systems at 4.0 mg/L and the secondary, non-enforceable standard at 2.0 mg/L. Both HHS/CDC and the EPA have discretion to update their guidance and recommendations and have done so in the past. Updating the USPHS guidelines involves a years-long, interagency and multi-stakeholder process that is likely to include review and input from external experts and a period for public comment and discussion. For example, following an internal process that developed its initial updated fluoridation recommendations, HHS published its proposed changes in 2011.  After further review and public comment periods, the final updated recommendations were published in 2015, and included a change to the recommended fluoride concentration in CWS, from 1.2 mg/L to 0.7 mg/L. The EPA set its 4.0 mg/L primary standard for fluoride in 1986, and by law the agency is required to review of drinking water standards (including fluoridation standards) at least every six years. The EPA’s most recent review of drinking water standards, released in July 2024, concluded that the current maximum fluoride level guideline is “not a candidate for revision at this time.” In the future, the EPA could decide to initiate a new review and assessment process for its fluoride guidelines.

Benefits and Risks from Water Fluoridation

Water fluoridation has been found to be effective in reducing the risk and severity of dental caries (tooth decay) in children (as well as adults). According to CDC, a review of the best available evidence shows water fluoridation reduces tooth decay by about 25% in children and adults, and evidence also shows that children living in communities where water is fluoridated have, on average, more than two fewer decayed teeth compared to similar children living in non-fluoridated communities. A comprehensive review of relevant studies, updated in 2024, concluded that evidence shows that initiation of water fluoridation reduces dental caries in children. A study from Juneau, Alaska found that cessation of fluoridation in that community was associated with increases in the number of dental caries, and the number of related procedures and treatments among Medicaid-eligible children.

At the same time, questions have been raised about health risks from exposure to high levels of fluoride concentrations, beyond current federal standards. Extended exposure to high levels of fluoride may have negative effects, such as contributing to dental fluorosis, a discoloration of teeth in young children. Recently, there have been more concerns raised about high levels of fluoride exposure and potential links to other conditions. For example, a 2024 U.S. National Toxicology Program (NTP) monograph suggests a potential link between high fluoride levels (above 1.5 mg per liter, more than double the USPHS recommended amounts for community water fluoridation) and lower IQ in children, but studies reviewed for that publication were from areas outside the U.S. with naturally high fluoride concentrations in their water. The monograph concludes that more studies are needed to fully understand the potential for lower levels (under 1.5 mg/L) of fluoride exposure to affect children’s IQ. Based in part on these findings, in September 2024, a US district judge ordered the EPA to take further regulatory action on fluoride, citing the potential risks to children’s neurological development; the EPA says it is reviewing the court decision, but no additional regulatory actions have been taken to date.

Status of Water Fluoridation in the U.S.

As of 2022, the CDC estimates that 72.3% of the U.S. population that is connected to community water systems (CWS) receives fluoridated water, or 62.8% of the U.S. population overall. Not all people are connected to CWS, as a proportion of the population accesses water through wells or other private sources. The overall percentage of the U.S. population with access to fluoridated water has barely changed over the last two decades: in 2006, CDC reported that 61.5% of the population was connected to fluoridated water, compared with 62.8% in 2022. Sometimes, naturally occurring fluoride exists in water systems, and in fact, can be higher than government benchmarks, including maximum recommended levels. According to CDC, as of 2020 about 1 million people in the U.S. (0.31% of the U.S. population) were connected to CWS that had naturally occurring fluoride levels equal to or greater than the EPA’s recommended limit of 2 mg/L.

The Majority of People in Most States Receive Fluoridated Water

Access to fluoridated water varies significantly across the country. As of 2022, data from 51 jurisdictions (50 states and Washington, D.C.) show there are seven jurisdictions where over 95% of the population is connected to fluoridated CWS (D.C., Kentucky, Minnesota, Illinois, North Dakota, Virginia, and Georgia) (Figure 1). However, in nine states less than 50% of the population is connected to fluoridated CWS (Hawaii, New Jersey, Oregon, Idaho, Montana, Louisiana, Alaska, Utah, New Hampshire, and Mississippi). These data largely reflect state and local statutes and regulations on fluoridation. Some states require fluoridation for communities above a certain population (including Kentucky, Minnesota, and Illinois), and have relatively high fluoridation rates as a result. Other states leave these decisions up to localities, many of which have decided not to fluoridate their water supplies. In Hawaii, the state with the lowest fluoridation coverage, no locality fluoridates their water systems (with the exception of military bases). Similarly, In New Jersey and Oregon, the states with the second and third lowest coverage rates, local fluoridation decisions have been contentious. More generally, localities are revisiting existing fluoridation policies and considering ending the practice, which typically has to be voted on by water supply recipients.

Rural areas and smaller communities are less likely to have access to fluoridated drinking water. People who live in rural areas are more likely to rely on private wells, which are not usually treated with fluoride, as opposed to public treated water systems. Additionally, smaller communities may face financial barriers that limit their ability to adequately treat their CWSs, decreasing access to fluoridated water for their residents.

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Women’s Health Insurance Coverage

Published: Dec 12, 2024

Health insurance coverage is an important factor in making health care affordable and accessible to women.1  Women with health coverage are more likely to obtain needed preventive, primary, and specialty care services, and have better access to new advances in women’s health. Among the 97.5 million women ages 19 to 64 residing in the U.S., most had some form of coverage in 2023. Over the past decade, the Affordable Care Act (ACA) has expanded access to affordable coverage through a combination of Medicaid expansions, private insurance reforms, and premium tax credits. However, while the uninsured rate has declined significantly in the past decade, gaps in private sector coverage, enrollment and eligibility barriers in publicly-funded programs, and persistent affordability challenges have left one in ten women uninsured. This factsheet reviews major sources of coverage for women residing in the U.S. in 2023, discusses the impact of the ACA on women’s coverage, and the coverage challenges that many women continue to face.

Sources of Health Insurance Coverage

Employer-Sponsored Insurance

Approximately 58.6 million women ages 19-64 (60%) received their health coverage from employer-sponsored insurance in 2023 (Figure 1).2 

Women's Health Insurance Coverage, 2023
  • Women in families with at least one full-time worker are more likely to have job-based coverage (70%) than women in families with only part time workers (33%) or without any workers (17%).3 
  • In 2023, annual insurance premiums for employer sponsored insurance averaged $8,435 for individuals and $23,968 for families. Family premiums have increased 43% over the last decade. On average, workers paid 17% of premiums for individual coverage and 29% for family coverage with the employers picking up the balance.

Non-Group Insurance

The ACA expanded access to the non-group or individually purchased insurance market by offering premium tax credits to help individuals afford coverage purchase through state-based health insurance Marketplaces. It also included many insurance reforms to alleviate some of the long-standing barriers to coverage (such as gender rating, lack of maternity coverage, and pre-existing conditions having a disproportionate effect on women) in the non-group insurance market. In 2023, about 9% of women ages 19 to 64 (approximately 8.4 million women) and 8% of their male counterparts purchased insurance in the non-group market.4  This includes individuals who purchased private policies from the ACA Marketplace in their state, as well as those who purchased coverage from private insurers that operate outside of Marketplaces.

  • Most individuals who seek insurance policies in their state’s Marketplace qualify for assistance with the costs of coverage. Individuals with incomes below $58,320 (400% of the Federal Poverty Level in 2023) can qualify for assistance in the form of federal tax credits which lower premium costs. The American Rescue Act (ARPA) of 2021, and subsequently the Inflation Reduction Act of 2022, have provided a temporary extension of Marketplace subsidies to people with higher income levels and led to record high enrollments in the ACA marketplace. These subsidies are set to expire at the end of 2025 and if they are not renewed, it would lead to a steep increase in insurance premium payments for ACA Marketplace enrollees. It is unclear whether the incoming Trump Administration plans to extend these subsidies or let them expire.
  • The ACA set new standards for all individually purchased plans, including plans available through the Marketplace as well as those that existed prior to the ACA. The ACA bars plans from charging women higher premiums than men for the same level of coverage (gender rating) or from disqualifying women from coverage because they had certain pre-existing medical conditions, including pregnancy. All direct purchase plans must also cover certain “essential health benefits” (EHBs) that fall under 10 different categories, including maternity and newborn care, mental health, and preventive care.

Medicaid

The state-federal program for individuals with low-incomes, Medicaid, covered 19% of adult women ages 19 to 64 in 2023, compared to 14% of men. Historically, to qualify for Medicaid, women had to have very low incomes and be in one of Medicaid’s eligibility categories: pregnant, mothers of children 18 and younger, a person with a disability, or over 65. Women who didn’t fall into these categories typically were not eligible regardless of how poor they were. The ACA allowed states to broaden Medicaid eligibility to most individuals with incomes less than 138% of the FPL regardless of their family or disability status, effective January 2014. As of December 2024, 40 states and DC have expanded their Medicaid programs under the ACA.

  • Medicaid covers the poorest population of women. Forty-four percent of women with low-incomes (below 200% FPL) and 52% of women living below the federal poverty level have Medicaid coverage.5 
  • By federal law, all states must provide Medicaid coverage to pregnant women with incomes up to 133% of the federal poverty level (FPL) through 60 days postpartum. However, in recent years, there has been a growing interest in expanding the length of the postpartum coverage period, and to date, all but two states have taken steps to extend postpartum Medicaid coverage to 12 months.
  • During the COVID-19 public health emergency (PHE), states provided continuous coverage to all Medicaid enrollees who had been enrolled in the program since March 18, 2020. This requirement ended on March 31, 2023, and states have gone through the process of redeterminations for Medicaid eligibility. In total, over 25 million Medicaid enrollees were disenrolled from the Medicaid program. Disenrollment rates varied across states and despite millions being disenrolled during the unwinding process, currently there are over 10 million more people enrolled in Medicaid than there were at the start of the pandemic.
  • Medicaid financed 41% of births in the U.S. in 2022, accounts for 75% of all publicly-funded family planning services and over half (61%) of all long-term care spending, which is critical for many frail elderly women.
  • Over half of the states have established programs that use Medicaid funds to cover the costs of family planning services for women with lower incomes who remain uninsured, and most states have limited scope Medicaid programs to pay for breast and cervical cancer treatment for certain low-income uninsured women.
  • Under federal law Medicaid coverage of abortion is very limited. The federal Hyde Amendment prohibits federal spending on abortions, except when the pregnancy is a result of rape or incest, or when it jeopardizes the life of the pregnant person. Twenty states use their own unmatched funds to pay for abortions for Medicaid enrollees who seek abortion in other circumstances. On June 24, 2022, the Supreme Court overturned Roe v. Wade, eliminating the federal Constitutional standard that had protected the right to abortion. Absent any federal standard addressing a right to abortion, states may set their own policies banning or protecting abortion. Among the 37 states and DC where abortion remains legal, 17 states and DC follow the Hyde restrictions, greatly limiting coverage for people who seek abortion care in those states.

Uninsured

On average, women have lower incomes and have been more likely to qualify for Medicaid than men under one of Medicaid’s eligibility categories; pregnant, parent of children under 18, disabled, or over 65. As a result, women are more likely than men to qualify for Medicaid and less likely to be uninsured. In 2023, 13% of men ages 19-64 were uninsured compared to approximately 10% of women in the same age bracket (9.3 million women).

Uninsured women often have inadequate access to care, get a lower standard of care when they are in the health system, and have poorer health outcomes. Compared to women with insurance, uninsured women have lower use of important preventive services such as mammograms, Pap tests, and timely blood pressure checks. They are also less likely to report having a regular doctor.

  • Women with lower incomes, women of color, and women who are non-citizens are at greater risk of being uninsured (Figure 2). One in five (17%) women with incomes under 200% of the FPL ($31,700 for an individual in 2023) are uninsured (Table 2), compared to 7% of women with incomes at or above 200% FPL. One in five Hispanic (20%) and American Indian and Alaska Native (19%) women are uninsured. A higher share of women in single parent households are uninsured (10%) than women in two-parent households (7%) (data not shown).6 
Health Insurance Coverage Among Non-Elderly Women by Selected Characteristics, 2023
  • The majority of women who are uninsured live in a household where someone is working: 69% are in families with at least one adult working full-time and 82% are in families with at least one part-time or full-time worker.7 
  • There is considerable state-level variation in uninsured rates across the nation, ranging from 20% of women in Texas to 3% of women in Hawaii, DC, Massachusetts, and Vermont (Figure 3). Of the 16 states with uninsured rates above the national average (10%), eight have not adopted the ACA Medicaid expansion.
Uninsured Rates Among Women Ages 19 to 64, by State, 2023
  • Many women who are uninsured are potentially eligible for financial assistance with coverage. Some are likely eligible for Medicaid but are not enrolled, while others qualify for subsidized Marketplace plans but may not be aware of coverage options or may face barriers to enrollment. However, in states that have not adopted the ACA Medicaid expansion, some women who are poor and uninsured fall into a “coverage gap” because they earn too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits. Other uninsured women are not eligible for any assistance with health coverage due to their immigration status, their income, or because they have an offer from an employer.

Scope of Coverage and Affordability

The ACA set national standards for the scope of benefits offered in private plans. In addition to the broad categories of essential health benefits (EHBs) offered by marketplace plans, all privately purchased plans must cover maternity care which had been historically excluded from most individually purchased plans. In addition, most private plans must cover preventive services without co-payments or other cost sharing. This includes screenings for breast and cervical cancers, well woman visits (including prenatal visits), prescribed contraceptives, breastfeeding supplies and supports such as breast pumps, and several STI services. There have been several legal challenges over elements of the preventive services policy, including in the pending case, Braidwood Management Inc. v. Becerra, which could affect whether the preventive services requirement remains intact in the future. Twenty-five states have laws banning coverage of most abortions from the plans available through the state Marketplaces. These restrictions were in place prior to the Supreme Court’s decision to overturn Roe v Wade.

Affordability of coverage continues to be a significant concern for many women, both for those who are uninsured as well as those with coverage. The leading reason why uninsured adults report that they haven’t obtained coverage is that it is too expensive. Under employer-sponsored insurance, the major source of coverage for women, 60% of all covered workers with a general annual deductible have deductibles of at least $1,000 for single coverage. Thirty-seven percent of women with employer sponsored coverage report that it is difficult to meet their deductibles.8 

Health Insurance Coverage of Women Ages 19-64 in 2023, by State

Health Insurance Coverage of Women Ages 19-64 With Lower Incomes in 2023, by State
Health Insurance Coverage of Reproductive Age Adult Women Ages 18 to 49 in 2023, by State
  1. This factsheet is based on KFF analysis of data from the American Community Survey (ACS), which stratifies data by an individual’s sex as male or female. Throughout this brief we refer to “women” but recognize that not all people who are born as females identify as “women.” ↩︎
  2. KFF estimates based on 2023 American Community Survey, 1-Year Estimates. ↩︎
  3. Ibid. ↩︎
  4. Ibid. ↩︎
  5. Ibid. ↩︎
  6.  KFF estimates based on 2023 American Community Survey, 1-Year Estimates. ↩︎
  7. Ibid. ↩︎
  8. KFF June 2019 Health Tracking Poll. ↩︎
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VOLUME 12

News Influencers, Opioid Disparities, and AI Bias in Healthcare

This is Irving Washington and Hagere Yilma. We direct KFF’s Health Misinformation and Trust Initiative and on behalf of all of our colleagues across KFF who work on misinformation and trust we are pleased to bring you this edition of our bi-weekly Monitor.

KFF Authors:

Irving Washington Irving Washington , and Hagere Yilma Hagere Yilma

Summary

This volume examines the role of news influencers in spreading misinformation to younger and polarized audiences, as well as misleading narratives about harm reduction amid disparities in opioid overdose rates affecting Black and Indigenous Americans. It also explores biases in artificial intelligence (AI) in healthcare and considerations for improving engagement with health information among marginalized communities and older adults.

Recent Developments

Generational and Political Differences in Accessing Reliable Health News: The Role of News Influencers

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A Pew Research Center poll found a shift in how Americans consume news, with 21% regularly turning to social media influencers for updates. These news influencers are primarily independent content creators with large followings, some of whom are journalists, who post about current events and civic issues on social media platforms. However, this shift toward influencer-based news may raise serious questions about the quality and accuracy of health information reaching the public. While some influencers provide credible insights, others spread false or misleading health claims. Even some influencers with medical credentials included in the sample study by Pew have spread false information about health topics like COVID-19. Other news influencers also contributed to the spread of health misinformation. For example, Joe Rogan, included in Pew’s sample of news influencers, has been criticized for using his platform to amplify false or misleading health information, including AIDS denialism and false claims about vaccine safety.

News influencers’ social media profiles can also be tied to their political ideologies, further complicating the landscape of health information. The Pew analysis found that most news influencers identify with certain political leanings, with right-leaning influencers outnumbering left-leaning influencers on most platforms. Among those who get news from influencers, conservative Republicans and liberal Democrats are more likely than moderate Republicans and Democrats to feel that the content they receive from influencers aligns with their own views. This dynamic can lead to a reinforced echo chamber, where followers consume information that supports their existing beliefs. Political figures who become influencers further complicate the landscape by blending their personal brands with their political roles, and using social media to promote their ideologies. Pew’s sample of news influencers included Mike Huckabee, former Arkansas Governor and nomination for U.S. Ambassador to Israel under the new Trump administration. Huckabee has used his social media platform to comment on health policy, including sharing misleading claims, such as equating abortions later in pregnancy with infanticide.

Addressing Misinformation About Naloxone as Opioid Overdose Remains High Among Black and Indigenous Americans 

Grace Cary / Getty Images

Although opioid deaths declined in 2023, a KFF analysis found disparities across race and ethnicity, with American Indian/Alaska Native (AIAN) and Black communities experiencing the highest rates of drug overdose deaths. Although opioid death rates began to show signs of decline across several demographic groups by 2023, the high vulnerability of AIAN and Black populations persists, reflecting broader systemic challenges, including limited access to treatment and harm reduction resources. Prior to naloxone becoming more widely available, research suggested that compared to White people, Black people had limited access to naloxone, a lifesaving drug that reverses opioid overdoses. Misinformation and stigma about naloxone may contribute to this disparity, such as the incorrect belief that naloxone leads to increased substance use. Fear of police harassment for carrying naloxone or being accused of drug possession can also deter people from accessing or using the drug, especially given the intersection of criminalization and substance use. Some public health campaigns aim to raise awareness about naloxone, but it is unclear whether these efforts are reaching or being received by Black and Indigenous communities. Addressing these issues along with affordability concerns may help address the lack of equitable access to naloxone.

Unsubstantiated Claims About Harm Reduction Programs Fuel Stigma

Cappi Thompson / Getty Images

False claims that harm reduction strategies promote drug use continue to surface in response to news about these programs, even when the news is positive. Harm reduction for opioids can involve various strategies to mitigate risks among users, such as syringe needle distribution and distribution of opioid overdose medications. For example, on November 14, NPR published an article about vending machines that provide free harm reduction tools like naloxone to anyone and sterile syringes to harm reduction clinic clients with a special code, explaining how these tools can help prevent overdose deaths and reduce the spread of infectious diseases. The article also prebunked false claims that harm reduction strategies may increase drug use and crime. Despite sharing this encouraging evidence, several Facebook users responded to NPR’s article with the false claim that harm reduction strategies promote drug use.

Recent misleading claims about harm reduction strategies have also come from public health officials. On October 16, two former top officials at the Department of Health and Human Services published an op-ed on Fox News claiming that the current administration’s harm-reduction strategies have “produced more harm, not less.” The authors claimed that harm reduction strategies promote “acceptance of a drug-using lifestyle.” On the day the article was published, Robert F. Kennedy Jr. shared it on X, stating, “Agreed. To end the opioid crisis we need common sense solutions not ‘harm reduction.’” Most comments agreed with the op-ed, with some falsely claiming that harm reduction strategies provide people with illegal drugs. The article continued to spread on social media platforms, where many posts and comments advocated against harm reduction, falsely claiming that harm reduction can “promote” drug use and discourage treatment.

Despite research showing that harm reduction strategies can prevent overdose deaths, reduce the spread of infectious diseases, and do not increase drug use or crime, the false claim that harm reduction promotes drug use persists. This may reveal public confusion about the goals and functions of harm reduction principles and programs, which aim to reduce the negative effects of drug use and link people to treatment if and when they are ready. Stigmatizing attitudes toward people who use drugs also suggest that the public may not understand that substance use disorder (SUD) is a chronic health condition and although some people are more at risk for it, SUD is fairly common, as nearly three in 10 U.S. adults say they or someone in their family has experienced opioid addiction.

AI & Emerging Technology

Addressing Racial Bias in AI used for Health Care

everythingpossible / Getty Images

Artificial intelligence (AI) is increasingly used in U.S. healthcare, but algorithms often embed racial and ethnic biases that perpetuate disparities in health outcomes. For example, algorithms used to predict health outcomes may inaccurately assess risks for minority groups due to underrepresentation in the training data. Research shows that AI systems often rely on data that overlooks factors such as a patient’s socioeconomic conditions (e.g., access to transportation or healthy food), leading to inaccurate treatment recommendations or misunderstandings about a patient’s ability to follow medical advice. Studies have also found that AI chatbots can share false medical myths about patients of color. Biases in AI systems are further exacerbated by historical inequities and a lack of transparency. Researchers suggest that reforms should focus on increasing diversity in clinical trials, incorporating socio-environmental factors into health care, and improving equity in algorithm development.

Polling Insight:

When it comes to health information, the public is not yet convinced that AI chatbots can provide accurate information. KFF’s June Health Misinformation Tracking Poll found that just one in three adults say they are “very confident” (5%) or “somewhat confident (31%) that the health information and advice they may come across on AI chatbot platforms is accurate (Figure 1). About six in ten adults say they are “not too confident” or “not at all confident.”

Notably, adults under age 50 and Black and Hispanic adults are somewhat more likely than those over age 50 and White adults, respectively, to say they have confidence in the accuracy of health information from AI chatbots, though about half or more across age and racial and ethnic groups say they are not confident.

Most Adults Are Not Confident in the Accuracy of Health Information from Chatbots 

Research Insights

Systemic Inequities and Resulting Distrust Make It Difficult for Marginalized Communities to Navigate Science Misinformation

FG Trade / Getty Images

A study published last year in Science Communication conducted focus groups of Black and Latino adults in Boston, MA to understand how historically excluded and marginalized populations perceive science-related issues and engage with misinformation. Participants expressed distrust of authority figures, celebrity endorsements, and fact-checking efforts. Many cited challenges in accessing accurate information due to institutional biases and systemic inequalities, such as discriminatory media algorithms and lack of representation in traditional newsrooms. Participants resonated most with health and wellness topics, especially messages that used storytelling, cultural figures, or social media as a guide. The findings suggest a need for culturally sensitive strategies, including leveraging trusted local leaders and improving access to multilingual, community-specific information to combat misinformation effectively.

Source: Amazeen, M. A., Vasquez, R. A., Krishna, A., Ji, Y. G., Su, C. C., & Cummings, J. J. (2024). Missing voices: examining how misinformation-susceptible individuals from underrepresented communities engage, perceive, and combat science misinformation. Science Communication, 46(1), 3-35.

Sharing Diverse Health Information and Mindfulness Techniques May Combat Information Fatigue in Older Adults

The Good Brigade / Getty Images

A study in Frontiers in Psychology examined how algorithm-driven content may contribute to information overload and avoidance in older adults. Because algorithms often prioritize similar or excessive information, older adults may become fatigued and avoid engaging with health content. The study suggests that mindfulness, the practice of staying focused and non-judgmental, may help mitigate this effect. While mindfulness does not directly reduce fatigue from information overload, it helps individuals engage more effectively with health information. The findings highlight the importance of providing diverse, accessible health content and incorporating mindfulness techniques to improve how older adults process and respond to health-related information.

Source: Zhong, F., & Gu, C. (2024). The impact of health information echo chambers on older adults avoidance behavior: the mediating role of information fatigue and the moderating role of trait mindfulness. Frontiers in Psychology, 15, 1412515.

About The Health Information and Trust Initiative: the Health Information and Trust Initiative is a KFF program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem. Our goal is to be of service to everyone working on health misinformation, strengthen efforts to counter misinformation, and build trust. 

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Support for the Health Information and Trust initiative is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF and KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities. The Public Good Projects (PGP) provides media monitoring data KFF uses in producing the Monitor.

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Donor Government Funding for Family Planning in 2023

Authors: Adam Wexler, Jennifer Kates, Stephanie Oum, and Eric Lief
Published: Dec 12, 2024
Section:
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Key Findings

This report provides an analysis of donor government funding for family planning in low- and middle-income countries in 2023, the most recent year available, as well as trends over time. It includes both bilateral funding from donor governments and their contributions to the United Nations Population Fund (UNFPA). It is part of an effort by KFF to track such funding that began after the London Summit on Family Planning in 2012. Overall, donor government funding for family planning increased in 2023, returning to prior year levels, but still below its peak in 2019.

Key findings include the following:

  • Family planning funding from donor governments was US$1.47 billion in 2023. Most funding is provided bilaterally (US$1.4 billion or 95%). The remainder – US$69.6 million (5%) – is for multilateral contributions to UNFPA’s core resources, adjusted for an estimated family planning share.
  • This represents an increase of 7% (US$101.1 million) in 2023 compared to US$1.37 billion in 2022 and is a return to prior year levels, but still below its peak reached in 2019 (US$1.58 billion).1 
  • The overall increase was due to increased bilateral funding from most donor governments; multilateral funding (contributions to UNFPA’s core resources) declined slightly largely due to decreases by Germany, Sweden, and the U.S.2 
  • Total funding increased from five donor governments in 2023 (Canada, Germany, the Netherlands, Norway, and the U.K.).3  Funding from the U.S. remained flat, and three countries decreased – Australia, Denmark, and Sweden.4  These trends were the same after accounting for exchange rate fluctuations, except for Sweden, which increased in currency of origin.5 
  • The U.S. continued to be the largest donor to family planning in 2023, accounting for 40% (US$582.5 million) of total funding from governments, followed by the Netherlands (US$246.5 million, 17%), the U.K. (US$198.6 million, 13%), Sweden (US$124.5 million, 8%) and Canada (US$112.2 million, 8%). However, when family planning funding is standardized by the size of donor economies, the Netherlands ranked first, followed by Sweden, and Norway; the U.S. ranked 7th.

The future of donor government support for family planning, however, is uncertain. A second Trump administration will almost certainly see an end to U.S. support for UNFPA, and proposed cuts to bilateral funding, as was seen in his first term. Moreover, the extent to which other donors will fill in any gaps created by the U.S. is unclear, as they face their own financial pressures and changes in leadership. Such uncertainties, and potential funding reductions, would create new challenges for reaching people in low- and middle-income countries with family planning services.

Report

Introduction

This report provides data on donor government funding for family planning activities in low- and middle-income countries in 2023, the most recent year available, as well as trends over time. It is part of an effort by KFF that began after the London Summit on Family Planning in 2012 and includes data from all 32 members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC). Data are collected directly from the largest donors and supplemented with data from the DAC. Direct data collection was carried out for nine donor governments that account for 97% of total funding for family planning. Both bilateral assistance and core contributions to UNFPA, adjusted for a family planning share, are included. For more detail, see methodology.

Findings

Total Funding

In 2023, donor government funding for family planning through bilateral and multilateral channels totaled US$1.47 billion, an increase of US$101.1 million, or 7%, compared to 2022 (US$1.37 billion). While this marks a return to prior year levels, it is below the peak level reached in 2019 (US$1.58 billion) (see Figure 1 & Table 1). The increase was entirely due to increased bilateral support from the majority of donor governments; multilateral funding decreased slightly (see “Bilateral Funding” and “Multilateral Funding” sections below).

Donor Government Funding for Family Planning, 2012-2023 (in billions)

Total funding increased from five donor governments in 2023 (Canada, Germany, the Netherlands, Norway, and the U.K.).6  Funding from the U.S. remained flat, and three countries decreased – Australia, Denmark, and Sweden.7 ,8  These trends were the same after accounting for exchange rate fluctuations, except for Sweden, which increased in currency of origin.9  There were, however, some differences among the donor governments in the amount of bilateral and multilateral funding provided between 2022 and 2023 (see Bilateral and Multilateral sections below).

Donor Government Funding for Family Planning, 2012-2023 (in current US$, millions)

The vast majority of donor government funding for family planning is provided bilaterally (95%). The remainder (5%) is for multilateral contributions to UNFPA’s core resources, adjusted based on the share used to support family planning activities. All donor governments provided a larger share of their family planning funding bilaterally (see Figure 2).

Family Planning Funding from Donor Governments by Funding Channel, 2023

The U.S. continued to be the largest government donor to family planning in 2023, accounting for 40% (US$582.5 million) of total donor government funding (see Figure 3). The Netherlands was the second largest donor (US$246.5 million or 17%), followed by the U.K. (US$198.6 million or 13%), and Sweden (US$124.5 million or 8%).

Donor Government Funding as Share of Total Disbursements for Family Planning, 2023

Bilateral Funding

Bilateral disbursements for family planning from donor governments – that is, funding disbursed by a donor on behalf of a recipient country or region – totaled US$1.40 billion in 2023, an increase of US$111.2 million, or 9%, compared to 2022 (US$1.29 billion) (see Appendix Table 1).

Bilateral funding from six donor governments (Canada, Germany, the Netherlands, Norway, Sweden, and the U.K.) increased in 2023 (see Figure 4).10  Two donor governments (Australia and Denmark) decreased funding in 2023, while the U.S. remained flat. These trends were the same after accounting for exchange rate fluctuations.

Changes in Donor Government Bilateral Funding for Family Planning (2022-2023)

The U.S. and U.K. have been the top two donors over the entire period since the London Summit (2012-2023). However, U.S. funding has been relatively flat while funding from the U.K., which fluctuated over the period, has declined in recent years. When these two are removed, bilateral funding from the other donor governments has generally increased over the period; although, there have been fluctuations (see Figure 5).

Trends in Bilateral Family Planning Funding from Donor Governments, 2012-2023 (in millions)

Multilateral Funding

While the majority of donor government assistance for family planning is provided bilaterally, donors also provide support for family planning activities through core contributions to the United Nations Population Fund (UNFPA) (where donors direct or earmark funding for specific family planning activities, such as for UNFPA Supplies, these are included as part of bilateral funding). In 2023, UNFPA estimates that 18% of its core funding was directed to family planning activities.11 

These totaled US$69.6 million in 2023, a decrease of US$10.1 million compared to 2022 (US$79.7 million) (see Appendix Table 2). The decrease was entirely due to a decline in total contributions to UNFPA’s core resources – largely from Germany, Sweden, and the U.S, rather than a change in the share of core resources UNFPA directed to family planning activities.12 ,13  Norway was the largest donor government to UNFPA’s core resources, followed by Germany, Sweden, and the Netherlands.

Fair Share

We looked at two different measures to assess the relative contributions of donor governments, or “fair share”, to family planning (see Table 2) as follows: rank by share of total donor government disbursements for family planning, and rank by funding for family planning per US$1 million in gross domestic product (GDP).

  • Rank by share of total donor government funding for family planning: By this measure, the U.S. ranked first in 2022, followed by the Netherlands, the U.K., Sweden, and Canada. The U.S. has consistently ranked #1 in absolute funding amounts over the entire period since the London Summit (2012-2023).
  • Rank by funding for family planning per US$1 million GDP: When funding for family planning is standardized by the size of donor economies (GDP per US$1 million), the Netherlands ranks at the top, followed by Sweden, Norway, and the U.K. (Figure 6); the U.S. ranks 7th.
Assessing Fair Share Across Donors, 2023
Donor Government Ranking by Funding for Family Planning per US$1 Million GDP, 2023

This work was supported in part by the Bill & Melinda Gates Foundation. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Adam Wexler, Jen Kates, and Stephanie Oum are with KFF. Eric Lief is an independent consultant.

Methods

Totals presented in this analysis include both bilateral funding for family planning in low- and middle-income countries as well as the estimated share of donor government contributions to UNFPA’s core resources that are used for family planning. Amounts are based on analysis of data from the 32 donor government members of the Organisation for Economic Co-operation and Development (OECD) Development Assistance Committee (DAC) in 2023 who had reported Official Development Assistance (ODA). Bilateral and multilateral data were collected from multiple sources.

Bilateral Funding:

Bilateral funding is defined as any earmarked (family planning designated) amount and includes family planning-specific contributions to multilateral organizations (e.g., non-core contributions to UNFPA Supplies). For purposes of this analysis, funding was counted as family planning if it met the OECD CRS purpose code definition: “Family planning services including counselling; information, education and communication (IEC) activities; delivery of contraceptives; capacity building and training.”

The research team collected the latest bilateral funding data directly from nine governments: Australia, Canada, Denmark, Germany, the Netherlands, Norway, Sweden, the United Kingdom, and the United States during 2023 (see Appendix Table 3). Direct data collection from these donors was desirable because they represent the preponderance of donor government assistance for family planning and the latest official statistics – from the Organisation for Economic Co-operation and Development (OECD) Creditor Reporting System (CRS) (see: http://www.oecd.org/dac/stats/data) – do not include all forms of international assistance (e.g., funding to countries such as Russia and the Baltic States that are no longer included in the CRS database). In addition, the CRS data may not include certain funding streams, such as family planning components of mixed-purpose grants to non-governmental organizations, provided by donors. Data for all other OECD DAC member governments – Austria, Belgium, Czech Republic, the European Union, Estonia, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Lithuania, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland – which collectively accounted for approximately 3 percent of bilateral family planning disbursements, were obtained from the OECD CRS database and are from 2022 calendar year.

For some donor governments, it was difficult to disaggregate bilateral family planning funding from broader population, reproductive and maternal health totals, as the two are sometimes represented as integrated totals. In other cases, funding for family-planning-related activities provided in the context of other official development assistance sectors (e.g., humanitarian assistance, education, civil society) was included if identifiable (e.g., if donors indicate specific family planning percentages for mixed-purpose projects, or if it was possible to identify family planning specific funding based on project titles and/or descriptions).

With some exceptions, bilateral assistance data represent disbursements. A disbursement is the actual release of funds to, or the purchase of goods or services for, a recipient. Disbursements in any given year may include disbursements of funds committed in prior years and in some cases, not all funds committed during a government fiscal year are disbursed in that year. In addition, a disbursement by a government does not necessarily mean that the funds were provided to a country or other intended end-user. Enacted amounts represent budgetary decisions that funding will be provided, regardless of the time at which actual outlays, or disbursements, occur. In recent years, most governments have converted to cash accounting frameworks, and presented budgets for legislative approval accordingly; in such cases, disbursements were used as a proxy for enacted amounts.

Amounts presented are for the fiscal year period, which vary by country. The U.S. fiscal year runs from October 1-September 30. The Australian fiscal year runs from July 1-June 30. The fiscal years for Canada and the U.K. are April 1-March 31. Denmark, Germany, the Netherlands, Norway, and Sweden use the calendar year. The OECD uses the calendar year, so data collected from the CRS for other donor governments reflect January 1-December 31. Most UN agencies use the calendar year, and their budgets are biennial.

All data are expressed in US dollars (USD). Where data were provided by governments in their currencies, they were adjusted by average daily exchange rates to obtain a USD equivalent, based on foreign exchange rate historical data available from the U.S. Federal Reserve (see: http://www.federalreserve.gov/) or in some cases from the OECD. Funding totals presented in this analysis should be considered preliminary estimates based on data provided and validated by representatives of the donor governments who were contacted directly.

Specific notes pertaining to the donor governments where direct data collection was conducted are as follows:

  • Project-level data were reviewed for Canada, Denmark, Germany, the Netherlands, Norway, and Sweden to determine whether all or a portion of the funding could be counted as family planning.
  • Project-level data were also reviewed for France for 2012-2020, but comparable data were not available for 2021-2023, so totals for these years are based on the OECD DAC CRS database. Totals for 2021-2023 will be updated once comparable data become available. Starting with the report presenting 2022 funding amounts, totals for France were included under the amounts presented for all other DAC members; prior reports presented totals for France separately.
  • Funding attributed to Australia and the United Kingdom is based on a revised Muskoka methodology as agreed upon by donors at the London Summit on Family Planning in 2012.
  • For the U.S., funding represents final, Congressional appropriations (firm commitments that will be spent) to the U.S. Agency for International Development (USAID), rather than disbursements, which can fluctuate from year-to-year due to the unique nature of the U.S. budget process (unlike most other donors, U.S. foreign assistance funding may be disbursed over a multi-year period). U.S. totals for 2017-2020 also include some funding originally appropriated by Congress for UNFPA that was transferred to the USAID family planning & reproductive health (FP/RH) account due to specific provisions in U.S. law including the Kemp-Kasten amendment (see KFF “UNFPA Funding & Kemp-Kasten: An Explainer”).

Multilateral Funding:

UNFPA core contributions were obtained from United Nations Executive Board documents and correspond to amounts received during the 2023 calendar year, regardless of which contributor’s fiscal year such disbursements pertain to. Data were already adjusted by UNFPA to represent a USD equivalent based on date of receipts. UNFPA estimates of total family planning funding provided from core resources were obtained through direct communications with UNFPA representatives for 2012-2021; family planning funding estimates from UNFPA’s core resources for 2022-2023 are based on amounts reported on UNFPA’s Transparency Portal and designated as for “Ending the Unmet Need for Family Planning”.

UNFPA’s core resources are meant to be used for both programmatic activities (family planning, population and development, HIV/AIDS, gender, and sexual and reproductive health and rights) as well as operational support. Donor government contributions to UNFPA’s core resources were adjusted to reflect the share of core resources supporting family planning activities in a given year based on information from UNFPA. For instance, in 2023, UNFPA reported expenditures totaling US$500 million from core resources including US$92 million for family planning activities, which results in an estimated 18% of a donor government’s core contribution in 2023 being included in its total funding for family planning.14 ,15 

Other than core contributions provided by governments to UNFPA, un-earmarked core contributions to United Nations entities, most of which are membership contributions set by treaty or other formal agreement (e.g., United Nations country membership assessments), are not identified as part of a donor government’s family planning assistance even if the multilateral organization in turn directs some of these funds to family planning. Rather, these would be considered as family planning funding provided by the multilateral organization and are not included in this report.

Appendices

Donor Government Bilateral Funding for Family Planning, 2012-2023 (in millions)
Donor Government Core Contributions to UNFPA, Total & FP-Share (in millions)
Donor Government Disbursements for Family Planning - Explanatory Notes, 2023 (in current US$, millions)

Endnotes

  1. Family planning totals are different from those reported last year due to updated data received after the 2023 report was published. Donor amounts do not exactly sum up to total amounts due to rounding. ↩︎
  2. The U.S. decline in its core contribution to UNFPA in 2023 was due to a one-time increase that occurred in the previous year. In 2022, the U.S. core contribution to UNFPA included the direct appropriation (US$30.6 million) provided by Congress as well as a one-time US$20 million contribution provided by the Biden administration through available funding from the American Rescue Plan Act of 2021 (P.L. 117-2). ↩︎
  3. In 2023, the U.K. Foreign, Commonwealth and Development Office (FCDO) undertook an update of its family planning funding data including a move from reporting disbursements by fiscal year to calendar year. Updated data for the entire period were not at the time of publication. As such, U.K. totals for 2021-2023 are based on the calendar year; totals for 2012-2020 are still based on the U.K. fiscal year and will be updated in the next report (overall trends are not expected to change as a result of the forthcoming update). The 2021 and 2022 totals previously reported were considered preliminary estimates and have been revised. All U.K. totals are based on the revised-Muskoka methodology. ↩︎
  4. The assessment that total U.S. family planning funding was flat in 2023 compared to 2022 is based on the amounts specified by the U.S. Congress in annual appropriations bills. The family planning amounts specified by Congress were the same in 2022 and 2023. The U.S. family planning total for 2022 as presented in this report is slightly higher than 2023 due to a one-time additional contribution to UNFPA’s core resources provided by the Biden administration (see Multilateral section). ↩︎
  5. In most cases, donor governments provide funding data in their currency of origin, which are converted to U.S. dollars for this report (see Methods). ↩︎
  6. In 2023, the U.K. Foreign, Commonwealth and Development Office (FCDO) undertook an update of its family planning funding data including a move from reporting disbursements by fiscal year to calendar year. Updated data for the entire period were not at the time of publication. As such, U.K. totals for 2021-2023 are based on the calendar year; totals for 2012-2020 are still based on the U.K. fiscal year and will be updated in the next report (overall trends are not expected to change as a result of the forthcoming update). The 2021 and 2022 totals previously reported were considered preliminary estimates and have been revised. All U.K. totals are based on the revised-Muskoka methodology. ↩︎
  7. The assessment that total U.S. family planning funding was flat in 2023 compared to 2022 is based on the amounts specified by the U.S. Congress in annual appropriations bills. The family planning amounts specified by Congress were the same in 2022 and 2023. The U.S. family planning total for 2022 as presented in this report is slightly higher than 2023 due to a one-time additional contribution to UNFPA’s core resources provided by the Biden administration (see Multilateral section). ↩︎
  8. “Other DAC Countries”, which includes: Austria, Belgium, Czech Republic, European Union, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland, is not listed under any assessment of increasing, decreasing, or remaining flat because there may be differences among the donor governments included. ↩︎
  9. In most cases, donor governments provide funding data in their currency of origin, which are converted to U.S. dollars for this report (see Methods). ↩︎
  10. “Other DAC Countries”, which includes: Austria, Belgium, Czech Republic, European Union, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland, is not listed under any assessment of increasing, decreasing, or remaining flat because there may be differences among the donor governments included. ↩︎
  11. The family planning share of UNFPA’s core resources is based on several sources including: expenditure totals as reported in UNFPA’s annual report; family planning expenditure totals as presented on UNFPA’s Programme Expenses Portal (see here), and direct communication with UNFPA (see Methods). ↩︎
  12. The U.S. decline in its core contribution to UNFPA in 2023 was due to a one-time increase that occurred in the previous year. In 2022, the U.S. core contribution to UNFPA included the direct appropriation (US$30.6 million) provided by Congress as well as a one-time US$20 million contribution provided by the Biden administration through available funding from the American Rescue Plan Act of 2021 (P.L. 117-2). ↩︎
  13. “Other DAC Countries”, which includes: Austria, Belgium, Czech Republic, European Union, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland, is not listed under any assessment of increasing, decreasing, or remaining flat because there may be differences among the donor governments included. ↩︎
  14. UNFPA, “United Nations Population Fund, Statistical and financial review, 2023 – Annexes, Report of the Executive Director”; April, 2024. ↩︎
  15. UNFPA, Transparency Portal (see here); accessed November 2024. ↩︎
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Published: Dec 12, 2024

These reports provide data on donor government funding for family planning activities in low- and middle-income countries. It is part of an effort by KFF that began after the London Summit on Family Planning in 2012 and includes data from all 30 members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC), as well as non-DAC members where data are available. Collectively, these donor governments provide the bulk of international assistance for family planning activities. Both bilateral assistance and core contributions to UNFPA are included.

Latest version:

December 2024

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A Look at Nursing Facility Characteristics Between 2015 and 2024

Published: Dec 6, 2024

Nursing facilities provide medical and personal care services for nearly 1.2 million Americans. In response to high mortality rates during the COVID-19 pandemic and long-standing staffing shortages, the Centers for Medicare and Medicaid Services (CMS) released a highly-anticipated final rule that established minimum staffing standards for nursing facilities. These standards were part of the Biden Administration’s broader strategy to increase the quality of and access to Medicaid services and long-term care. Several lawsuits have been filed in opposition to the final rule, including lawsuits filed by nursing home industry groups, Texas’ attorney general, and a group of Republican state attorneys general. With President-elect Trump returning to the presidency, the staffing rule’s future is unknown. It is not clear whether the incoming Administration will defend the nursing home staffing final rule in court, support the litigation in opposition to the rule, or issue new regulations to scale back the provisions in the staffing rule. Additionally, during President Trump’s first term, the Administration issued regulations to relax oversight for nursing facilities, which included reducing the frequency of facility assessments, removing the requirement that an infection preventionist work at a facility part-time, and removing the 14-day prescription limit for psychotropic drugs.

This data note examines the characteristics of nursing facilities and the people living in them with data from Nursing Home Compare, a publicly available dataset that provides a snapshot of information on quality of care in each nursing facility, and CASPER (Certification and Survey Provider Enhanced Reports), a dataset that includes detailed metrics collected by surveyors during nursing facility inspections. State-level data are also available on State Health Facts, KFF’s data repository with downloadable health indicators. Key takeaways include:

  • The number of nursing facilities certified by CMS decreased by 5% between July 2015 and July 2024.
  • Over that same period, the average number of hours of nursing care that residents receive per day declined by 8% (from 4.13 to 3.80), despite generally increasing health needs of nursing facility residents.
  • The average number of deficiencies per facility increased during this time period as did the share of facilities with serious deficiencies, from 17% to 28%.

The number of nursing facilities certified by CMS decreased by 5% between July 2015 and July 2024 (Figure 1). In order to receive payment under the Medicare and/or Medicaid programs, nursing facilities are required to follow certain regulations and be certified by CMS. The decreased number of nursing facilities reflects the net change in the number of certified facilities after accounting for newly-certified facilities and facilities that are no longer certified, including facilities that closed. Between 2015 and 2024, the number of residents living in nursing facilities decreased by 10%, with a steep decline between 2020 and 2021 reflecting the effects of the COVID-19 pandemic (Figure 1). Since the steep drop in 2021, resident counts have slowly started to rise but are still well below pre-pandemic levels. Prior to the pandemic, the number of residents was declining more slowly, which reflects a longer-term trend of people increasingly receiving care in home and community-based settings (HCBS) rather than institutional settings. COVID-19 exacerbated the decrease in nursing facility residents—in part because nursing facility residents and staff incurred so many deaths during the pandemic.

The Number of Certified Nursing Facilities and Residents Is Lower Than in 2015

Between July 2015 and July 2024, the average hours of care from registered nurses, licensed practical nurses, and nurse aides that nursing facility residents received declined by 8%, from 4.13 hours to 3.80 hours per resident each day (Figure 2). The decrease was driven by a 21% decline in registered nurse (RN) hours and an 8% decline in nurse aide hours. Licensed practical nurse (LPN) hours increased by 6% in this same time period. The 2024 rule on nursing facility staffing requires nursing facilities to meet minimum standards in staff hours for RNs and nurse aides but does not include any requirements for LPNs. The growing use of LPNs and declining number of RNs and nurse aide hours is one reason that fewer than 1 in 5 nursing facilities had staffing levels sufficient to meet the rule’s requirements as of April 2024, according to KFF analysis. The total hours from nursing staff decreased between 2015 and 2024, but the number of hours of care per resident rose briefly in 2021. The relatively higher staffing hours in 2021 reflected the fact that the number of residents declined more quickly than the number of staff hours did between 2020 and 2021. In 2021, the number of staffing hours was 12% lower than in 2020 (data not shown). These lower staffing levels in the last several years align with data as of March 2024 showing that the number of workers employed at long-term care facilities continues to remain below pre-pandemic levels.

The Average Hours of Care Nursing Facility Residents Receive Per Day Is Lower Than in 2015

Box 1: Direct Care Staff in Nursing Facilities

Registered Nurse (RN): Registered nurses (RNs) are responsible for the overall delivery of care to the residents and assess needs of nursing facility residents. RNs are typically required to have between two and six years of education.

Licensed Practical Nurse (LPN) and Licensed Vocational Nurse (LVN): LPNs/LVNs provide care under the direction of an RN. Together, RNs and LPNs/LVNs make sure each resident’s plan of care is being followed and their needs are being met. LPNs/LVNs typically have one year of training.

Certified Nurse Aides/Assistants (CNAs): CNAs work under the direction of a licensed nurse to assist residents with activities of daily living such as eating, bathing, dressing, assisting with walking/exercise, and using the bathroom. All CNAs must have completed a nurse aide training and competency evaluation program within 4 months of their employment. They must also pursue continuing education each year.

Both the average number of deficiencies and the share of facilities with serious deficiencies has increased over time, which could reflect increased oversight and lower staffing levels (Figure 3, Box 2). Between 2015 and 2024, the average count of deficiencies increased from 6.8 to 9.5, an increase of 40%. The increase was generally steady overtime, except for a stable period between 2020 and 2022. The share of facilities reporting serious deficiencies between 2015 and 2024 increased from 17% to 28%. The Nursing Home Staffing Study report by Abt Associates from June 2023 found that better-staffed nursing homes are typically cited for fewer deficiencies or violations of federal regulations, suggesting there may be a relationship between the increase in deficiencies and the decrease in staffing levels over the same time period.

Box 2: Deficiencies in Nursing Facilities

Nursing facilities receive deficiencies when they fail to meet the requirements necessary to receive federal funding. Deficiencies are often given for problems which may have negative effects on the health and safety of residents. Commonly cited deficiencies include a failure to provide necessary care, failure to report abuse or neglect, and violation of infection control requirements. Each of these categories has specific regulations that state surveyors review to determine whether or not facilities have met the standards.

Deficiencies are characterized by their level of severity: Deficiencies for “actual harm” or “immediate jeopardy” are the most severe and are grouped together under the term, “serious deficiencies.” CMS defines “actual harm” as a “deficiency that results in a negative outcome that has negatively affected the resident’s ability to achieve the individual’s highest functional status.” “Immediate jeopardy” is defined as a deficiency that “has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the nursing facility.”

Deficiency Counts and Severity Are Higher Than in 2015

The share of residents by primary payer stayed relatively stable over time (Figure 4). As of July 2024, Medicaid was the primary payer for 63% of nursing facility residents; Medicare for 13% of residents; and the remaining 24% of residents had another primary payer (ex. private insurance, out-of-pocket, etc.) (Figure 4). Medicare does not generally cover long-term care but does cover up to 100 days of skilled nursing facility care following a qualifying hospital stay. KFF polling shows that four in ten adults overall incorrectly believe that Medicare is the primary source of insurance coverage for low-income people who need nursing facility care.

The share of facilities by ownership type also stayed relatively stable over time (Figure 4), but there was increasing scrutiny over the 72% of facilities that are for profit during the prior Administration. Despite little change in the type of ownership, there have been reports of private equity firms purchasing nursing facilities and changing operations to increase profits, resulting in lower-quality care. Currently available data do not reliably identify whether facilities are owned by a private equity company, though the GAO estimates that about 5% of nursing facilities had private equity ownership in 2022. The Biden Administration issued a final rule (effective as of January 2024) that requires nursing homes enrolled in Medicare or Medicaid to disclose detailed information regarding their owners, operators, and management, including:

  • Anyone who exercises any financial control over the facility;
  • Anyone who leases or subleases property to the facility, including anyone who owns 5% or more of the total value of the property; and
  • Anyone who provides administrative services, clinical consulting services, accounting or financial services, policies or procedures on operations, or cash management services for the facilities.

Facilities must also disclose whether any of the owning or managing entities are a private equity company or real estate investment trust. It is unknown whether the income Administration will eliminate, strengthen, or maintain those requirements.

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Medicare Spent an Average of 27% More on People Who Switched from Medicare Advantage to Traditional Medicare Compared to Those Who Were Only in Traditional Medicare

Published: Dec 6, 2024

A new KFF analysis finds higher Medicare spending among people who switched from Medicare Advantage to traditional Medicare than for similar beneficiaries who were in traditional Medicare all along.

Medicare spent an average of 27% more on such beneficiaries, according to the analysis, which examined health costs in traditional Medicare for both groups in the year following the switch, after adjusting for differences in health status and other characteristics. This amounts to a difference of $2,585 in Medicare spending per person, on average, between the two groups in 2022. The difference in spending among people with certain health conditions varied from 15% for those with pneumonia to 34% for people with diabetes.  

The higher Medicare spending among beneficiaries who disenrolled from Medicare Advantage compared to similar beneficiaries in traditional Medicare was due to skilled nursing facility spending (34%), followed by outpatient hospital spending (23%), and inpatient hospital spending (20%), with some variation by chronic conditions and other beneficiary characteristics. 

In 2024, more than half of all eligible Medicare beneficiaries were enrolled in a Medicare Advantage plan. Other research has found that people who use relatively more health care services are less likely to sign up for one of the private plans and more likely to choose traditional Medicare.  

The higher Medicare spending among people who disenrolled from Medicare Advantage for traditional Medicare raises several questions, including whether such switchers were unable to get the medical care they felt they needed while enrolled in a Medicare Advantage plan; whether more Medicare Advantage enrollees would make the switch if people with pre-existing conditions did not face barriers to purchasing Medicare supplemental insurance (Medigap); and whether the disenrollments reduce costs and increase profits for Medicare Advantage insurers, and increase Medicare spending. 

The analysis also drills down to examine differences in Medicare spending between switchers and those who were continuously covered by traditional Medicare by health condition, age, race and ethnicity, and dual eligible status.For the full analysis and other data and analyses about Medicare Advantage, visit kff.org.

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Medicare Spending was 27% More for People who Disenrolled from Medicare Advantage than for Similar People in Traditional Medicare

Published: Dec 6, 2024
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Issue Brief

More than half (54%) of eligible Medicare beneficiaries are enrolled in a private Medicare Advantage plan in 2024. People are drawn to Medicare Advantage because most plans offer extra benefits and lower cost sharing compared to traditional Medicare without supplemental insurance, usually for no additional premium (other than the Part B premium). Medicare Advantage is also popular among lawmakers in Congress, both Republicans and Democrats, as well as President-elect Trump, whose previous administration generally supported policies that provided increased flexibilities to insurers when designing and administering these private plans.

Though Medicare Advantage is a popular choice for Medicare beneficiaries, there is some evidence that people who use relatively more health care services are less likely to choose a private plan and more likely to choose traditional Medicare. Previous analyses from KFF and the Medicare Payment Advisory Commission (MedPAC) found that people who enroll in Medicare Advantage have lower Medicare spending in the years before they enroll than similar people who remain in traditional Medicare, even after controlling for health status. This pattern may be partly attributable to concerns about the tools Medicare Advantage plans typically use to manage utilization and costs, such as prior authorization requirements and provider network restrictions.

This analysis looks at traditional Medicare spending among people who choose to disenroll from Medicare Advantage and obtain coverage under traditional Medicare during the annual Medicare open enrollment period. It compares their traditional Medicare spending (Parts A and B) in the year following disenrollment to similar people who were continuously covered by traditional Medicare (see Appendix for characteristics of each group), using data from the Medicare Master Beneficiary Summary File (MBSF) for 2021 and 2022 (see Methods).

Key Takeaways

  • Medicare spent 27% more, on average, for people who were covered by traditional Medicare after disenrolling from Medicare Advantage than for people who were continuously covered by traditional Medicare, after adjusting for differences in health status and other characteristics. This is a difference of $2,585 in Medicare spending per person, on average, between the two groups in 2022.
  • Differences in Medicare spending between people who disenrolled from Medicare Advantage and beneficiaries continuously in traditional Medicare varied by health condition, ranging from 15% for people with pneumonia to 34% for people with diabetes. For example, among people with certain cancers, Medicare spending was 28% ($4,907) higher, on average, among those who disenrolled from Medicare Advantage than among people continuously covered by traditional Medicare.
  • Differences in Medicare spending between people who disenrolled from Medicare Advantage and those continuously in traditional Medicare increased with age for Medicare beneficiaries ages 65 and over. For example, among people ages 85 and over the difference was 46% ($7,113) compared to 25% among people ages 65 to 69 ($1,843).
  • Differences in Medicare spending between people who disenrolled from Medicare Advantage and beneficiaries continuously in traditional Medicare were larger among Black (55%, $5,203) and Hispanic (54%, $4,434) beneficiaries than White beneficiaries (25%, $2,464).
  • People dually-eligible for Medicare and full Medicaid benefits who disenrolled from Medicare Advantage had spending that was 61% ($9,435) higher than their counterparts who were continuously in traditional Medicare, while the difference in spending for Medicare beneficiaries who do not receive Medicaid was 20% ($1,684).
  • Skilled nursing facility spending accounted for the largest share of the difference in average Medicare spending per person between people who disenrolled from Medicare Advantage and those continuously in traditional Medicare (34%), followed by outpatient hospital spending (23%), and inpatient hospital spending (20%), with some variation by chronic conditions and other beneficiary characteristics.

The substantially higher Medicare spending among people who disenrolled from Medicare Advantage, on average, compared to similar people who were continuously covered by traditional Medicare raises several questions. First, why are some Medicare Advantage enrollees choosing to disenroll from Medicare Advantage rather than get the medical care they need from their plan, and why are they receiving more medical care in the year following disenrollment than similar people who have been continuously covered by traditional Medicare?

Second, given how challenging it can be for people with pre-existing conditions to purchase Medicare supplemental insurance (Medigap) if they switch to traditional Medicare, and concerns about potentially high out-of-pocket costs under traditional Medicare without supplemental coverage, what share of Medicare Advantage enrollees would want to switch to traditional Medicare, but feel they cannot afford to do so?

Third, does the current payment system adequately account for adverse selection into traditional Medicare, which leads to higher Medicare Advantage benchmarks and higher payments to Medicare Advantage plans? Additionally, to what extent does the pattern of higher utilization and spending among people who disenroll from Medicare Advantage, reduce the costs incurred by insurers, increasing their profits and contributing to their ability to offer supplemental benefits? Finally, how does higher Medicare spending among people who disenroll from Medicare Advantage impact Medicare spending, and to what extent does it place added strain on the Medicare Hospital Insurance Trust Fund and increase beneficiary premiums?

People who disenrolled from Medicare Advantage had Medicare spending that was 27% more, on average, than spending for similar people continuously covered by traditional Medicare

Overall, people who disenrolled from Medicare Advantage had Medicare spending that was 27% ($2,585) higher, on average, than those continuously covered by traditional Medicare, after adjusting for differences in health risk factors (Figure 1).

Spending was $2,585 Higher (27%), on Average, Among People who Disenrolled from Medicare Advantage Compared to Those Continuously Covered by Traditional Medicare

Several studies have found that certain groups of Medicare Advantage enrollees switch to traditional Medicare at higher rates, including beneficiaries in their last year of life, those with higher health needs, and those dually eligible for Medicare and Medicaid. Furthermore, some groups with high disenrollment rates, such as beneficiaries in their last year of life, have higher health care spending after they disenroll compared to similar beneficiaries who are long-time recipients of traditional Medicare.

This analysis shows that spending differences are not limited to those particularly high-need groups because the spending differences persist after controlling for health risk, though the magnitude of the difference is greater, on average, for high-cost beneficiaries. While prior research finds lower health care spending among people who enroll in Medicare Advantage, in the year prior to enrollment, this analysis shows that people who disenroll from Medicare Advantage use more services and incur higher Medicare costs in the year following disenrollment than similar beneficiaries who were continuously covered under traditional Medicare.

People who disenrolled from Medicare Advantage had higher spending, on average, than those continuously covered by traditional Medicare across all chronic health conditions examined

People who disenrolled from Medicare Advantage had higher Medicare spending, on average, across all chronic health conditions examined, after adjusting for other health risk factors, than those continuously covered by traditional Medicare (Figure 2, Appendix Table 2). Differences in average per person spending varied by condition, ranging from 15% ($5,187) for people with pneumonia to 34% ($4,586) for people with diabetes. The largest difference in Medicare spending per person in dollar terms between people who disenrolled from Medicare Advantage and those continuously in traditional Medicare was among people with Alzheimer’s disease or other dementias ($7,451), followed by stroke ($6,660), and atrial fibrillation ($6,147). Among people with certain cancers, including breast, colorectal, endometrial, lung, prostate, and urologic cancers, spending for people who disenrolled from Medicare Advantage was 28% ($4,907) higher than for people continuously covered by traditional Medicare.

Spending Differences Between People who Disenrolled from Medicare Advantage and Those Continuously Covered by Traditional Medicare are Higher, on Average, Among Chronically Ill Beneficiaries Across All Chronic Conditions Examined

People with greater health needs may see multiple health care providers and require numerous specialty services, resulting in a greater burden from the limited provider networks, prior authorization, and referral requirements Medicare Advantage plans often employ. Prior authorization is most often required for high-cost services, such as chemotherapy and other Part B drugs, inpatient hospital stays, and stays in skilled nursing facilities. In addition, narrow provider networks may limit available options for treatment of certain conditions. For instance, prior studies have found that Medicare Advantage enrollees are less likely than traditional Medicare beneficiaries to receive care from the highest rated hospitals for treatment of cancer or cancer-related surgical procedures.

Average differences in Medicare spending between people who disenrolled from Medicare Advantage and those continuously covered by traditional Medicare increased with age among beneficiaries ages 65 and older

Across all age groups, people who disenrolled form Medicare Advantage had higher Medicare spending, on average, than those continuously covered by traditional Medicare. Average differences in per person spending increased with age among older beneficiaries, from 25% ($1,843) among those ages 65-69 to 46% ($7,113) among those ages 85 and older. People under the age of 65, who qualify for Medicare due to long-term disability, have somewhat higher average spending per person than Medicare beneficiaries between the ages of 65 and 74, and the differences in spending among this group between those who disenrolled from Medicare Advantage and those continuously covered by traditional Medicare were also somewhat larger (39%, $3,348) (Figure 3).

Spending Differences Between People who Disenrolled from Medicare Advantage and Those Continuously Covered by Traditional Medicare Increased with Age, on Average, Among Beneficiaries Ages 65 and Older

Average differences in Medicare spending between people who disenrolled from Medicare Advantage and those continuously covered by traditional Medicare were higher among Black and Hispanic than White beneficiaries

Across all racial and ethnic groups examined, people who disenrolled from Medicare Advantage had higher Medicare spending, on average, than those continuously covered by traditional Medicare. Average differences in per person spending were approximately two times higher among Black (55%, $5,203) and Hispanic (54%, $4,434) beneficiaries than among White beneficiaries (25%, $2,464) (Figure 4).

Spending Differences Between People who Disenrolled from Medicare Advantage and Those Continuously Covered by Traditional Medicare are Higher, on Average, Among Black and Hispanic Beneficiaries, Compared to White Beneficiaries

Average differences in Medicare spending between people who disenrolled from Medicare Advantage and those continuously covered by traditional Medicare were higher among people dually eligible for Medicare and full Medicaid benefits

Among dual-eligible beneficiaries who qualified for full Medicaid benefits, those who disenrolled from Medicare Advantage had spending that was 61% ($9,435) higher, on average, than those continuously covered by traditional Medicare. Average differences in per person spending were smaller among beneficiaries who were not dual-eligible (20%, $1,684) and among dual-eligible beneficiaries who qualified for assistance with Medicare premiums, and in some cases cost sharing, but not full Medicaid benefits (partial-benefit dual-eligible beneficiaries) (49%, $4,114) (Figure 5).

Spending Differences Between People who Disenrolled from Medicare Advantage and Those Continuously Covered by Traditional Medicare are Higher, on Average, Among People Dually Eligible for Medicare and Full Medicaid Benefits, Compared to Those with Partial or No Medicaid Benefits

Skilled nursing facility and hospital care accounted for more than three-quarters of the average difference in Medicare spending between people who disenrolled from Medicare Advantage and those continuously covered by traditional Medicare

Skilled nursing facility services accounted for the largest share (34%, $877) of the average difference in per person spending between people who disenrolled from Medicare Advantage and those continuously covered by traditional Medicare, followed by outpatient hospital services (23%, $596) and inpatient hospital services (20%, $505) (Figure 6).

Skilled Nursing Facility Care Accounted for One-Third of the Average Difference in Spending Between People who Disenrolled from Medicare Advantage and those Continuously Covered by Traditional Medicare

For certain groups, the total difference in average per person spending between people who disenrolled from Medicare Advantage and those continuously covered by Medicare Advantage was largely driven by skilled nursing facility services. These included dual-eligible beneficiaries with full Medicaid benefits (62%), beneficiaries ages 80 to 84 (59%) and ages 85 and older (55%), and beneficiaries with pneumonia (85%), Alzheimer’s disease or other dementias (74%), stroke (74%), and heart failure (73%) (Appendix Table 3). By contrast, skilled nursing facility services made up a smaller share of the total difference in average spending among people under age 65 (20%) and those ages 65 to 69 (14%).

Among other groups, inpatient hospital services made up a larger share of the difference in average spending, including among beneficiaries under age 65 with long-term disabilities (48%), as well as among beneficiaries with asthma (47%), glaucoma (33%), and chronic obstructive pulmonary disease (33%). Beneficiaries with certain cancers had among the highest share of the total difference in average spending attributed to outpatient hospital services (34%), a similar share attributed to skilled nursing facility services (30%) and a relatively modest share of the difference attributed to spending on inpatient hospital services (18%).

Consistent with this analysis, a recent report by the majority staff of the Senate Permanent Subcommittee on Investigations found that Medicare Advantage plans are more likely to deny prior authorization requests for coverage of post-acute care, such as skilled nursing facility stays, than for other types of services.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Appendix

Selected Demographic Characteristics of Beneficiaries who Disenrolled from Medicare Advantage, Compared to Those Continuously Covered by Traditional Medicare
Average Spending Per Person Among Beneficiaries who Disenrolled from Medicare Advantage, Compared to Those Continuously Covered by Traditional Medicare
Average Difference in Spending Per Person by Service Category Among Beneficiaries who Disenrolled from Medicare Advantage, Compared to Those Continuously Covered by Traditional Medicare

Methods

This analysis uses data from the 20% Medicare Master Beneficiary Summary File (MBSF) and Medicare claims files to compare Medicare spending (across Parts A and B) for beneficiaries who were previously enrolled in Medicare Advantage (Disenrolled from Medicare Advantage) to beneficiaries who have been continuously covered by traditional Medicare (Always Traditional Medicare). The Disenrolled from Medicare Advantage cohort includes people who were enrolled in Medicare Advantage in 2021 and in traditional Medicare in 2022. The Always Traditional Medicare cohort of beneficiaries were enrolled in traditional Medicare in both 2021 and 2022.

To be included in either cohort, beneficiaries had to have 12 months of coverage under Medicare Part A and Part B in 2021, as well as coverage in Parts A and B in all months in 2022 they were enrolled in Medicare (i.e., not deceased). The analysis includes all 50 states and DC. People with ESRD are excluded because 2021 was the first year people with ESRD were broadly eligible to enroll in a Medicare Advantage plan. For the Disenrolled from Medicare Advantage cohort, the analysis excludes people who were enrolled in a cost plan, Medicare Medicaid plan, or PACE plan in 2021.

Compared to the Always Traditional Medicare cohort, a somewhat larger share of the Disenrolled from Medicare Advantage cohort were ages 65 to 69 (24% vs. 17%), Black (10% vs. 7%) or Hispanic (7% vs. 5%), or dually eligible for Medicare and full Medicaid benefits (16% vs. 12%). There were also differences in the share of beneficiaries with certain health conditions (Appendix Table 1). To account for differences in age, dual eligibility, and health status, the risk score for each person was calculated using the CMS-HCC Risk Adjustment model based on diagnoses present in 2022. Note that the risk model is used to adjust payments to Medicare Advantage plans and does not account for race. Thus our approach also does not control for race and ethnicity.

Compared to all people enrolled in Medicare Advantage in 2021, those who disenrolled were more likely to have been covered by traditional Medicare in 2020 than those who stayed enrolled in Medicare Advantage. Specifically, among people who disenrolled from Medicare Advantage, 31% were covered by traditional Medicare in 2020; among people who stayed in Medicare Advantage, 11% were in traditional Medicare in 2020. These differences may be driven by the ability for people to return to the same Medigap policy within 12-months after switching to Medicare Advantage for the first time (note, Medicare beneficiaries are limited to a single “trial period”), relieving concerns about Medigap underwriting or cost sharing without a supplemental policy for some subset of people who disenrolled. We are unable to determine what share of the people who disenrolled from Medicare Advantage were in their “trial period” because it was the first time they had tried Medicare Advantage.

Our approach to analyzing spending follows the approach used by MedPAC in calculating average spending for people who switch from traditional Medicare to Medicare Advantage compared to those who remain in traditional Medicare. First, all Medicare payments, beneficiary liability, and other primary payer payments for all Part A and Part B services were summed for each person in the sample for Calendar Year 2022. Next, each person’s total spending is divided by their risk score (calculated using the CMS-HCC Risk Adjustment model and 2022 diagnoses) to derive risk-standardized spending, which allows for comparisons on an apple-to-apple basis for people with differences in health risk (such as differences in diagnosed health conditions). Within each county, the risk-standardized spending for each cohort is then averaged. To estimate spending given the health risk of the population of people who disenrolled from Medicare Advantage, the risk-standardized spending is then multiplied by the average risk score of people who disenrolled from Medicare Advantage. The national average spending for each cohort is then calculated as a weighted average of each county spending, using the number of people who disenrolled from Medicare Advantage as the weight. Counties in which no beneficiaries disenrolled from Medicare Advantage are excluded from the analysis. For each subgroup analysis a similar approach is followed, limiting the sample to people with the specific characteristic.

The Medicare Chronic Conditions Warehouse definitions for chronic conditions were used as a basis for identifying people with specific chronic conditions. To maintain consistency across the cohorts, only the 2022 claims were used. At least 1,000 members of the Disenrolled from Medicare Advantage cohort had to have a chronic condition for it to be included in the list.

Additionally, to test the sensitivity of the analysis, spending was modeled using a regression that controlled for risk score and county. The regression was specified using both a general linear model with a log link and a probit model. The average difference in each case was similar to those presented in this brief.

Overview of Medicare Advantage Payments

Medicare pays Medicare Advantage plans, in part, based on county-level spending for similar people in traditional Medicare, though payments may be higher or lower depending on a range of factors, such as a plan’s quality star rating, the county in which it operates, and the amount requested annually by the plan (referred to as a plan’s “bid”).

Plans that bid above traditional Medicare spending must charge enrollees an additional premium to make up the difference in cost. A growing number of plans choose to bid below traditional Medicare spending, which allows them to recoup a portion of the savings as a “rebate.” Rebates must be put towards certain plan features, such as lower cost-sharing, reductions to enrollees’ Part B or Part D premiums, or extra benefits (such as dental, vision, and hearing) not included in traditional Medicare. Payments are further adjusted to reflect the health status of enrollees, as well as certain other characteristics, such as age, sex, and Medicaid enrollment. Plans whose enrollees are expected to incur larger health costs receive larger payments (a process referred to as “risk adjustment”).

The Medicare Payment Advisory Commission estimates that payment to Medicare Advantage insurers is 122% of Medicare spending for similar beneficiaries covered by traditional Medicare. The higher payments are driven by favorable selection into Medicare Advantage and more intense coding of diagnoses among these plans. Those higher payments allow Medicare Advantage insurers to offer additional benefits and lower out-of-pocket spending, but place pressure on the hospital insurance trust fund and raise Medicare Part B premiums for all beneficiaries, including those in traditional Medicare.

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