Since the opioid epidemic was declared a public health emergency in 2017, it has claimed 454,464 lives, with opioid-related deaths rising by 67% between 2017 and 2023. Initially driven by prescription opioids and heroin, the epidemic has shifted in recent years, with illicit synthetic fentanyl—a substance 100 times more potent than morphine—now dominating most markets. Even a small amount of fentanyl can be lethal, and in 2023, 7 in 10 counterfeit opioid pills contained a deadly dose.

Although provisional CDC data show a decline in opioid deaths in 2023, the death toll remains much higher than just a few years ago, keeping this issue in the spotlight. Both former President Trump and Vice President Harris have records related to addressing the opioid epidemic, but they also have proposed different approaches to ongoing and future efforts to address the issue. Trump’s 2024 campaign emphasizes a stricter law enforcement strategy aimed at reducing trafficking, primarily through reinstating and tightening border policies and tougher punishment, including the death penalty for “traffickers and drug smugglers.” In contrast, the Biden-Harris administration’s multi-pronged strategy includes reducing supply, expanding harm reduction, and improving access to treatment, with Harris placing a stronger emphasis on increasing fentanyl seizures through enhanced detection technology at the border and ports. Along with the 1 in 3 adults who report in a KFF survey that they or a family member have been addicted to opioids (29%) or illegal drugs (27%), both President Biden and Vice-Presidential hopeful J.D. Vance have close family members who have experienced addiction.

This analysis examines opioid overdose deaths from the last two decades (2003-2023), with a particular focus on the decline in deaths observed in the last six months of 2023. Opioid overdose deaths include fatalities from intentional acts (suicide or homicide), unintentional acts (poisoning or drug assault), or cases of unknown intent. Regardless of other substances involved, any death with opioid involvement is classified as an opioid overdose death. According to provisional 2023 CDC WONDER data, fewer than 1% of deaths remain undetermined. Key takeaways from this analysis include the following:

• Fentanyl-involved opioid deaths drove rises in overall overdose deaths, by over 23-fold from 2013 to 2023, while prescription opioid deaths stayed steady and heroin deaths declined.
• In the second half of 2023, opioid overdose deaths started to decline, and by December 2023, they were 20% fewer than there were in December 2022. While it is unclear how much any specific policy may have contributed to the decline, a number of policies were implemented, including those focused on reducing supply of fentanyl, increasing treatment, and improving access to harm reduction supplies—such as opioid overdose reversal medication.
• Opioid death rates varied widely by race, ethnicity, age, and sex. In the second half of 2023, White people saw the largest decline (-14%) while declines in other racial and ethnic groups were much smaller. Opioid deaths increased for people 65+, while falling in all other age groups.
• In 2023, opioid death rates were the highest in WV, DC, and DE (71.4, 49.9, and 47.5/100,000, respectively), while states with the lowest opioid death rates included NE, SD, and IA (4.3, 5.7, and 8.4/100,000, respectively). In three-quarters of states, opioid deaths declined in the last six months of 2023 compared to the same period in 2022.

What are the trends in opioid deaths?

The sharp rise in drug deaths in recent years was driven by fentanyl deaths. Fentanyl-involved opioid deaths surged more than 23-fold over the last decade, while prescription opioid deaths remained steady and heroin deaths declined. Fentanyl deaths more than doubled during the pandemic, increasing from 36,359 in 2019 to 73,838 in 2022 (Figure 1). Illicit synthetic fentanyl (referred to as fentanyl for simplicity) is inexpensive to produce and often mixed into other drug supplies, such as methamphetamine and cocaine. In addition to increases in fentanyl supply, other factors, such as pandemic-related stressors, disruptions in treatment, and other life challenges, as well as insufficient treatment infrastructure and a shortage of skilled providers, may have contributed to rises in opioid deaths.

In the second half of 2023, opioid overdose deaths began to decline and continued to fall through the end of the year. In July 2023, deaths were 2% lower than in July 2022, and by December, they were 20% lower compared to December 2022. Looking at 2023 alone, opioid deaths dropped from 6,928 in July to 5,841 in December, a decrease of over 1,000 deaths (Figure 2). Early provisional and partial data for the first quarter of 2024 point to a continuation of this downward trend through early 2024.

Non-opioid overdose deaths also fell in the last half of 2023 compared to the previous year, though the decline was smaller (-3% vs. -10% for opioid deaths) (Figure 3). Non-opioid deaths refer to drug overdose deaths that did not involve opioids, such as those involving only non-opioid drugs, like cocaine or methamphetamine. Non-opioid deaths account for a much smaller share, about one-third, of overall drug overdose deaths.

While it is too early to determine if the decline in opioid overdose deaths will continue, several federal policies aimed at reducing deaths may have played a role. The Biden-Harris administration’s strategy for the opioid epidemic focuses three key areas: expanding harm reduction and public awareness, improving access to treatment and supports, and reducing the supply and spread of illicit drugs, particularly fentanyl. FDA’s approval of the first over the counter opioid overdose medication likely increased public access to the medication. Federal opioid response grants and settlement funds supported low-barrier distribution of naloxone and other harm reduction tools, like fentanyl test strips, while campaigns like the DEA’s “One Pill Can Kill,” raised public awareness of fentanyl risks. Federal policies extended or permanently relaxed in-person requirements for methadone and buprenorphine treatment. Federal investments in the broader mental health services, such as 988 and mobile crisis, may have also contributed, perhaps through connections to care. Efforts to reduce fentanyl supply are also ongoing, with increased seizures at U.S. borders and ports of entry.

How do opioid death rates vary across demographics groups?

In 2023, opioid death rates were highest among American Indian/Alaska Native (AIAN) and Black people, individuals aged 26 to 44, and males (Figure 4). AIAN and Black people had the highest death rates across race and ethnicity, at 49.8 and 37.9 per 100,000, respectively. Earlier in the opioid epidemic, overdose rates were highest among White people, but this trend shifted with opioid death rates for Black people surging over 700%, compared to a 140% rise for White people in the past decade. The high rates of opioid deaths among American Indian and Alaska Native (AIAN) people mirrors broader worsening trends in behavioral health, including the highest and fastest-growing suicide and overall drug overdose rates. Among age groups, those aged 26 to 44 had the highest death rates, followed by those aged 45 to 64. Although people aged 12-17 and 65+ have lower overall rates, these groups have seen substantial increases in recent years. In 2023, opioid death rates among males were more than double those of females, with males also experiencing the largest increase over the past decade, rising 238%.

Opioid overdose deaths decreased across most racial and ethnic groups from the last 6 months of 2023 compared to the same period in 2022, but drops were greater among White people (-14%) compared to other racial and ethnic groups (-2 to -6%, Figure 5). The larger decline in these deaths among White people may reflect racial disparities in access to OUD treatment. Prior KFF analyses found that White people were more likely to have access to medications used to treat OUD compared to Black and Hispanic people. The uptake of medication treatment services is also low among AIAN people.

While opioid overdose deaths decreased for all non-elderly age groups in the last six months of 2023, they increased for elderly adults (65+). Young adults saw the largest decline (-23%) in opioid deaths from the second half of 2023 compared to the second half of 2022. The rise in overdose deaths among elderly adults (9%) during the same period may be linked to challenges in detecting and treating substance use disorder (SUD) in this group, as symptoms can be mistaken for age-related decline. When a SUD is identified, stigma, decreased social support, transportation, and physical comorbidities can complicate access to treatment services—along with few SUD treatment programs that are designed for geriatric adults. Older adults have higher rates of opioid prescriptions, but co-prescribing of overdose reversal medication is low.

How do opioid death rates vary across states and how have they changed?

Opioid overdose death rates varied widely across states in 2023, from 4.3 per 100,000 in Nebraska to 71.4 per 100,000 in West Virginia (Figure 6). Nebraska, South Dakota, and Iowa had the lowest rates, with 4.3, 5.7, and 8.4 deaths per 100,000 people, respectively. West Virginia had the highest rate at 71.4 per 100,000—over 40% higher than the next highest rate in D.C., which was 49.9 per 100,000. The national opioid death rate was 24.1 per 100,000, with 33 states having rates within 10 deaths per 100,000 of the national death rate (Figure 5).

The last 6 months of 2023 brought drops in opioid deaths nationally and in about three quarters of states, compared to the same months in 2022 (Figure 7). Over this period, opioid overdose deaths decreased the most in North Carolina (-41%), remained relatively steady in New Mexico and Mississippi (-1%, +1%, respectively), and increased the most in Alaska (+58%).

States can develop their own approaches to addressing the opioid epidemic or build on federal initiatives, but state actions vary. State decisions about allocation of state opioid response grants and settlement funds for low barrier access to naloxone and other harm reduction tools, as well as efforts to ease access to treatment vary by state and may impact outcomes. Some states, like Virginia, have invested in campaigns to expand awareness about fentanyl in drug supplies, building on federal messaging campaigns like the DEA’s “One Pill Can Kill.” State decisions on Medicaid coverage and limits for certain populations and substance use services, along with whether to adopt federal opportunities that expand treatment and health coverage to high-risk groups, such as incarcerated individuals nearing release, may also influence outcomes.

Health care affordability has been a longstanding concern in the U.S., including among older adults, many of whom have relatively low incomes and modest assets to help pay medical bills. Medicare offers important financial protection by providing health insurance coverage to 67 million people in the U.S., including adults age 65 or older and younger adults with long-term disabilities. Coverage of Medicare benefits is provided through either traditional Medicare or Medicare Advantage private plans. Enrollment in Medicare Advantage plans has grown rapidly in recent years, partly because most Medicare Advantage plans charge no premium (other than the Part B premium) and offer extra benefits not available in traditional Medicare such as dental, vision, and hearing benefits. Most people with Medicare also have other coverage, such as Medicaid, Medigap, and employer coverage, which may pay some or all of their Medicare cost-sharing requirements and may also provide benefits that Medicare does not cover.

This brief analyzes the different types of coverage that people with Medicare have and the demographic characteristics of Medicare beneficiaries with different types of coverage, based on the Centers for Medicare & Medicaid Services Medicare Current Beneficiary Survey, 2022 Survey file data (MCBS) (the most recent year of data available, see Methods for details).

Key highlights:

• In 2022, Medicare enrollment was split equally between Medicare Advantage and traditional Medicare. Overall, more than 4 in 10 Medicare beneficiaries (44%), including beneficiaries in traditional Medicare and Medicare Advantage, had additional coverage from an employer or union sponsored plan (24%) or Medicaid (19%).
• Nearly 90% of people in traditional Medicare had some form of additional coverage, such as Medigap (42%), employer or union-sponsored retiree health benefits (31%), or Medicaid (16%), but 11% (three million Medicare beneficiaries) had no additional coverage.
• More than 40% of all Medicare Advantage enrollees also had some form of coverage from Medicaid (23%) or a union/employer sponsored retiree health plan (18%) in 2022.
• Beneficiaries in traditional Medicare with Medigap and employer-sponsored insurance had higher incomes, were in relatively good health, had more years of education, and were less likely to be under age 65 with disabilities than all traditional Medicare beneficiaries.
• As more beneficiaries have shifted to Medicare Advantage plans, the number of Medicare beneficiaries in traditional Medicare with no additional coverage has declined from 5.6 million in 2018 to 3.2 million in 2022. Traditional Medicare beneficiaries with no supplemental coverage were more likely to be under the age of 65 and have relatively lower incomes compared to traditional Medicare beneficiaries overall.
• Medicare Advantage enrollees were more likely to be Black or Hispanic, self-report relatively poor health, have incomes below $20,000 per person, and have lower levels of education, compared to traditional Medicare beneficiaries in 2022.
• Dual-eligible individuals accounted for a larger number and share of Medicare Advantage enrollees (7.0 million; 23%) than traditional Medicare beneficiaries (4.6 million; 16%) in 2022. Dual-eligible individuals in both traditional Medicare and Medicare Advantage were more likely to have lower incomes, self-report relatively poor health, identify as Black or Hispanic, and be under age 65 with disabilities than the overall Medicare population. 

Sources of Coverage

Among the 59.6 million people enrolled in both Medicare Part A and Part B in 2022, enrollment was split equally between Medicare Advantage and traditional Medicare (Figure 1). Most people in traditional Medicare had some form of additional coverage, such as Medicaid, retiree health benefits through an employer or Medigap, but three million Medicare beneficiaries (5%) had no additional coverage. While Medicare Advantage enrollment has surpassed 50% of total Medicare enrollment as of 2024, MCBS data beyond 2022 is not yet available.

Characteristics of Medicare Beneficiaries, By Source of Coverage

Traditional Medicare

Among the 29.7 million Medicare beneficiaries in traditional Medicare in 2022, most (89%) had some type of additional coverage, either through Medigap (42%), employer coverage (31%), Medicaid (16%), or another source (1%). But 1 in 10 (11%) of Medicare beneficiaries in traditional Medicare had no additional coverage (Figure 1, Appendix Table 1). A more detailed discussion of these types of coverage and the characteristics of people in each category is below.

Medigap

Medicare supplement insurance, also known as Medigap, covered 2 in 10 (21%) Medicare beneficiaries overall, or 42% of those in traditional Medicare (12.5 million beneficiaries) in 2022. Medigap policies, sold by private insurance companies, fully or partially cover Medicare Part A and Part B cost-sharing requirements, including deductibles, copayments, and coinsurance. Medigap limits the financial exposure of Medicare beneficiaries and provides protection against catastrophic medical expenses. For example, a previous KFF report found that a smaller share of traditional Medicare with additional sources of coverage, such as Medigap, reported cost-related problems than Medicare Advantage enrollees or traditional Medicare beneficiaries without additional coverage. However, Medigap premiums can be costly for beneficiaries living on modest incomes and can rise with age, among other factors, depending on the state in which they are regulated.

Compared to all traditional Medicare beneficiaries in 2022, beneficiaries with Medigap were more likely to be White, have higher annual incomes (above $20,000 per person), self-report excellent, very good, or good health, and have a bachelor’s degree or higher (Figure 2, Appendix Table 1).

In contrast, a smaller share of traditional Medicare beneficiaries under age 65 have a Medigap policy than traditional Medicare beneficiaries ages 65 and older (2% versus 11%). Federal law provides a 6-month guarantee issue protection for adults ages 65 and older when they first enroll in Medicare Part B if they want to purchase a supplemental Medigap policy, but these protections do not extend to adults under the age of 65, who qualify for Medicare due to having a long-term disability. Most states do not require insurers to issue Medigap policies to beneficiaries under age 65, and most do not extend guarantee issue protections to people over age 65 beyond the one-time Medigap open enrollment period.

Employer Coverage

In total, 14.5 million Medicare beneficiaries – a quarter (24%) of Medicare beneficiaries overall – also had some form of employer or union-sponsored health insurance coverage in 2022 in addition to Medicare Part A and Part B. Of this total, 9.1 million beneficiaries had employer coverage in addition to traditional Medicare (31% of beneficiaries in traditional Medicare), while 5.4 million beneficiaries were enrolled in Medicare Advantage employer group plans (see Medicare Advantage section below; estimates do not sum to total due to rounding). People with both Medicare Part A and Part B and employer- or union-sponsored coverage are likely to be retirees for whom Medicare is primary.

Compared to traditional Medicare beneficiaries overall in 2022, beneficiaries with employer or union-sponsored coverage in addition to traditional Medicare were more likely to have higher incomes ($40,000 or greater per person), a bachelor’s degree or higher, self-report excellent or good health, have no limitations in activities of daily living (ADLs), and were less likely to be under age 65 (Figure 2, Appendix Table 1).

Separately, in 2022, an estimated 5.6 million Medicare beneficiaries had Part A only, a group that primarily includes people who were active workers (either themselves or their spouses) and had primary coverage from an employer plan and Medicare as a secondary payer. People with Part A only cannot enroll in a Medicare Advantage plan, so people with coverage through Medicare Advantage employer group plans are likely to be retired.

Medicaid

Medicaid, the federal-state program that provides health and long-term services and supports coverage to low-income people, was a source of supplemental coverage for 11.6 million Medicare beneficiaries with low incomes and modest assets in 2022, or 19% of all Medicare beneficiaries. A larger number of Medicare beneficiaries with Medicaid (known as dual-eligible individuals) were enrolled in a Medicare Advantage plan (7.0 million) than in traditional Medicare (4.6 million people) (see Medicare Advantage section below) (Appendix Table 1). For these beneficiaries, Medicaid typically pays the Medicare Part B premium and may also pay a portion of Medicare deductibles and other cost-sharing requirements. Most dual-eligible individuals are also eligible for full Medicaid benefits, including long-term services and supports. Dual-eligible individuals who are not eligible for full Medicaid benefits receive partial benefits, including assistance with Medicare premiums and, in many but not all cases, Medicare cost-sharing requirements.

Compared to traditional Medicare beneficiaries overall in 2022, dual-eligible individuals were more likely to have low incomes and relatively low education levels, self-report fair or poor health, identify as Black or Hispanic, and be under the age of 65 (Figure 2, Appendix Table 1).

(Estimates of the number of dual-eligible beneficiaries in this analysis may differ from other KFF estimates due to different data sources and methods used; see methods below for details.)

No additional coverage

In 2022, more than 3 million Medicare beneficiaries overall (5%) – 11% of all beneficiaries in traditional Medicare – had no other insurance coverage. Traditional Medicare beneficiaries with no additional coverage are fully exposed to Medicare’s cost-sharing requirements, which would mean paying a $1,632 deductible for a hospital stay in 2024, daily copayments for extended hospital and skilled nursing facility stays, and a $240 deductible plus 20% coinsurance for physician visits and other outpatient services. (These costs are in addition to $174.70 per month (around $2,000 per year) for the standard Part B premium for all of 2024). Beneficiaries in traditional Medicare without additional coverage also face the risk of high annual out-of-pocket costs because there is no cap on out-of-pocket spending for Part A and B services in traditional Medicare, unlike in Medicare Advantage plans.

Beneficiaries in traditional Medicare without any form of additional coverage were more likely to have low and modest incomes (between $10,000 and $40,000 per person) compared to all traditional Medicare beneficiaries in 2022, and include a relatively large share of people on Medicare with disabilities who are under the age of 65 (Figure 2, Appendix Table 1). Medicare beneficiaries with annual incomes between $10,000 and $40,000 per person have limited ability to afford Medigap premiums and are unlikely to qualify for Medicaid because their income and assets are not low enough to meet eligibility guidelines. Further, because they are more likely to self-report fair or poor health than beneficiaries with incomes of $40,000 or more, they may be more likely to have higher out-of-pocket expenses, further exacerbated by the lack of an out-of-pocket limit in traditional Medicare.

The number and share of traditional Medicare beneficiaries without any form of supplemental coverage has steadily declined in recent years. Between 2018 and 2022, the number of traditional Medicare beneficiaries without supplemental coverage declined from 5.6 million beneficiaries (10% of the total Medicare population, or 17% of those in traditional Medicare) to 3.2 million (5% of the total Medicare population, or 11% of those in traditional Medicare). This decline likely reflects the increase in Medicare Advantage enrollment over time, which has increased from 20 million in 2018 to 33 million in 2024.

Medicare Advantage

In 2022, Medicare Advantage covered half of all Medicare beneficiaries (50%), or 29.9 million people with Medicare. (Medicare Advantage enrollment in 2024 now totals 33 million, or 54% of all eligible beneficiaries.)

Of the total number of Medicare Advantage enrollees in 2022, most (59%) were enrolled in plans available to all Medicare beneficiaries, but 5.4 million (18%) were enrolled in employer- or union-sponsored group plans. Under these arrangements, employers or unions contract with an insurer and Medicare pays the insurer a fixed amount per enrollee to provide benefits covered by Medicare. A growing share of large employers with retiree health obligations are offering these benefits through Medicare Advantage plans.

Another 7.0 million Medicare Advantage enrollees in 2022 (23%) also had Medicaid coverage, and were enrolled in either a Special Needs Plan (SNP) or a Medicare Advantage plan generally available to all Medicare beneficiaries. SNPs restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs, including beneficiaries dually eligible for Medicare and Medicaid (D-SNPs), people with severe chronic or disabling conditions (C-SNPs), and beneficiaries requiring a nursing home or institutional level of care (I-SNPs).

Compared to traditional Medicare beneficiaries in 2022, Medicare Advantage enrollees were more likely to be Black or Hispanic, have incomes below $20,000 per person, live in urban areas, and have lower levels of education (Figure 3, Appendix Table 1). In addition, dual-eligible individuals account for a larger share of Medicare Advantage enrollees (23%) than traditional Medicare beneficiaries (16%).

Immigrant adults are a diverse population who make up 16% of adults in the United States and play a significant role in the nation’s workforce and communities. Leading up to the 2024 election, there has been an increase in anti-immigrant rhetoric and immigration has been a central talking point for candidates. The Trump campaign has repeatedly described immigrants as a source of crime, a burden for taxpayers, and a drain on government programs like Medicare and Social Security. The Harris campaign has also focused on immigration, emphasizing her tough on crime stance as a former attorney general of a border state, while also highlighting her family’s immigrant roots. Some states have also taken restrictive actions focused on immigrants, including requiring hospitals to collect patient immigration status.

Amid this rhetoric and these recent state actions, data on immigrants’ health care use and costs as well as their contributions to the economy and workforce, including in the health care sector, can be informative. This brief provides key data on these topics drawing on KFF analysis across a range of data sources, including the KFF/LA Times Survey of Immigrants, the largest nationally representative survey of immigrants conducted to date, and other research.

Immigrants are not more likely than U.S.-born citizens to report using government assistance for food, housing, or health care, and undocumented immigrants remain ineligible for federally funded assistance.

The 2023 KFF/LA Times Survey of Immigrants shows that, despite having lower household incomes and facing financial challenges, immigrant adults are no more likely than U.S.-born adults to say that they or someone living with them received government assistance with food, housing, or health care in the past year. Overall, about a quarter (28%) of both immigrant adults and U.S.-born citizen adults say they received this type of assistance in the past 12 months (Figure 1).

Lawfully present immigrants face eligibility restrictions for federal programs, including Medicaid and the Children’s Health Insurance Program (CHIP). In general, lawfully present immigrants must have a “qualified status” to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll even if they meet other eligibility requirements. Some lawfully present immigrants, such as refugees and asylees, are exempt from the five-year waiting period. States can also expand coverage to lawfully residing immigrant pregnant people and children without a five year wait. Lawfully present immigrants can purchase Affordable Care Act (ACA) Marketplace coverage and receive tax credits to offset the cost of that coverage without a five-year wait. Lawfully present immigrants can also qualify for Medicare but must have sufficient work history. If they do not have this work history, they can purchase Medicare Part A after residing legally in the U.S. for five years continuously.

Undocumented immigrants are not eligible to enroll in federally funded coverage including Medicaid, CHIP, or Medicare, or to purchase coverage through the ACA Marketplaces. Medicaid payments for emergency services may be made to hospitals or other providers on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. Emergency conditions include those that place an individuals’ health in serious jeopardy or cause serious bodily impairment or dysfunction, although states have discretion to determine what services can be reimbursed through Emergency Medicaid.

Some states have established fully state-funded programs to provide coverage to immigrants regardless of immigration status, although they vary in eligibility and scope of benefits provided. Research suggests that expanding health coverage for immigrants can reduce uninsurance rates, increase health care use, lower costs, and improve health outcomes.

Immigrants, particularly those who are undocumented, use less health care, including emergency room care, than people born in the U.S.

Overall, research shows that immigrants, including lawfully present and undocumented immigrants, use less health care than U.S.-born citizens. Moreover, the KFF/LA Times Survey of Immigrants shows that among immigrant adults, likely undocumented immigrants are less likely than lawfully present immigrants and naturalized citizens to report seeking or receiving care in the U.S. or having a health care visit in the past year. About six in ten (63%) likely undocumented immigrant adults report a health care visit in the past year compared with 74% of lawfully present immigrant adults and 82% of naturalized citizen adults.

Lower use of health care among immigrants likely reflects a combination of them being younger and healthier than their U.S.-born counterparts as well as them facing increased barriers to care, including language access challenges, confusion, and immigration-related fears. Prior KFF analysis found that Trump-era policies amplified these fears and contributed to greater reluctance to access care.

Immigrants have lower health care costs than U.S.- born people.

Reflecting their lower use of health care, immigrants have lower health care expenditures than their U.S.-born counterparts. KFF analysis of 2021 medical expenditure data shows that, on average, annual per capita health care expenditures for immigrants are about two-thirds those of U.S.-born citizens ($4,875 vs. $7,277) (Figure 3). This reflects lower spending for most types of health care, including office-based visits, prescription drugs, inpatient care, outpatient care, and dental care. These findings are consistent with other research which shows that immigrants’ overall health expenditures are one-half to two-thirds of those of U.S.-born individuals, regardless of status, and that per capita expenditures from private and public insurance sources are lower for immigrants, particularly for undocumented immigrants. For example, one study found that undocumented immigrants are more likely to be uninsured and have significantly lower health care expenditures than U.S.-born individuals per year, and that despite differences in the likelihood of being uninsured, there are no significant differences in rates of uncompensated care between undocumented immigrants and U.S.-born individuals.

Immigrants contribute to the economy through their role in the workforce and tax payments, with research showing that they help subsidize health care for U.S.- born people and stabilize Medicare and Social Security.

Immigrants support the nation’s workforce by filling unmet labor market needs, and research suggests that they do not take jobs away from U.S.-born people. They play a disproportionate role filling jobs in essential industries such as construction and agriculture that are at increased risk of adverse health outcomes and injuries, including climate-related health hazards. In addition, immigrants as well as the adult children of immigrants play outsized roles in the health care workforce as physicians, surgeons, nurses, and long-term care workers (Figure 4). As health care workforce shortages are projected to continue and the U.S. 65 and older population grows, immigrants could help mitigate these shortages.

Analysis shows that undocumented immigrants contribute billions in federal, state, and local taxes each year. It is estimated that more than a third of their tax dollars are payroll taxes that fund programs they cannot access, including Social Security, Medicare, and the federal share of unemployment insurance. Research further finds that immigrants pay more into the health care system through taxes and health insurance premiums than they utilize, helping to subsidize health care for U.S.-born citizens. Earlier research found that without the contributions undocumented immigrants make to the Medicare Trust Fund, it would reach insolvency earlier, and that undocumented immigrants result in a net positive effect on the financial status of Social Security.

On July 26, 2024, CMS approved North Carolina’s plan to incentivize hospitals with enhanced Medicaid payments to relieve up to $4 billion in existing medical debt for nearly 2 million people and to implement policies designed to prevent future medical debt. The state aims to improve the health and well-being of North Carolinians while supporting the financial sustainability of its hospitals. Many people face difficulties affording medical care and prescription drugs in the U.S., even those with insurance. Four in ten U.S. adults have debt due to medical bills. People with disabilities or in worse health, people with lower incomes, and people who are uninsured are more likely to have medical debt. A KFF poll suggests that people with medical debt are more likely to delay or skip needed care to avoid incurring more debt, cut back on other basic household expenses, take money out of retirement or college savings, or increase credit card debt. People with medical debt are also more likely to have other forms of financial distress. In September 2024, the Census Bureau released poverty measure estimates for 2023, including changes in poverty after accounting for certain “elements” (e.g., certain federal assistance or certain expenses). Among the elements included, “medical expenses” had the greatest effect on increasing the number of people in poverty in 2023—by an estimated 7.4 million.

Vice President Harris has supported efforts to address medical debt. In June 2024, Harris announced a proposal to remove medical debt from most credit reports and to prohibit lenders from using medical debt information to make credit eligibility determinations. Under the Biden-Harris administration, state and local governments have leveraged economic relief funds (from the American Rescue Plan Act) to cancel an estimated $7 billion in medical debt for up to nearly 3 million Americans. Building on these efforts, Harris has proposed to work with states to cancel medical debt for millions of Americans and to help them avoid accumulating medical debt in the future if she is elected president. This policy watch examines medical debt in North Carolina and the state’s new plan to leverage the state Medicaid program to address medical debt.

What is the burden of medical debt in North Carolina?

North Carolina was among the states with the highest reported share of adults (13.4%) with medical debt (2019-2021, pre- Medicaid expansion). The share of adults with medical debt varies considerably across the U.S. The national annual average (2019-2021) was 8.6%. The share of adults with medical debt is likely higher in the South because 7 states in the South (of 16) have not adopted the ACA Medicaid expansion, and the region has higher uninsured rates compared to other regions. In December 2023, North Carolina became the latest state to implement the expansion, reducing the number of low-income uninsured people without access to Medicaid.

According to KFF Health News reporting, many hospitals engage in aggressive collection practices that can have significant financial consequences for patients. However, little is known about hospital debt collection practices across the country and the medical debt carried by their patients. A 2023 report from Duke University and the North Carolina Office of State Treasurer found North Carolina hospitals sued thousands of patients from January 2017 through June 2022, generating millions of dollars in judgments for hospitals. Interest charges and other additional fees accounted for about a third of the total judgments against patients. Patients who had been sued by North Carolina hospitals described in interviews financial stress from the lawsuits, negative impacts on their physical health, and fear of seeking future health care.

How is North Carolina leveraging the state’s Medicaid program to provide medical debt relief?

The state is using its Medicaid program to incentivize hospitals to relieve medical debt for eligible North Carolinians and to prevent the accumulation of medical debt going forward. States are generally prohibited from directing how Medicaid managed care plans pay providers; however, states may implement certain “state directed payments” that require plans to adopt minimum or maximum provider payment fee schedules or provide uniform dollar or percentage increases (above negotiated base payment rates) to network providers (also see Box 1). When North Carolina implemented the ACA Medicaid expansion in 2023, the state also began the Healthcare Access and Stabilization Program (HASP), a state directed payment program for hospitals, as part of a broader strategy to support access to care for low-income North Carolinians. To incentivize hospitals to relieve medical debt (and prevent the future accumulation of debt), the state amended “HASP” to increase hospital state directed payments (to average commercial rates) for inpatient and outpatient hospital services for hospitals that agree to certain conditions (see Table 1). All of North Carolina’s eligible hospitals (99 hospitals) have committed to participating in the debt relief program (as of August 2024), which the state estimates may relieve up to $4 billion in existing medical debt for nearly 2 million low- and middle-income North Carolinians.

Over 25 million people were disenrolled from Medicaid and over 56 million had their coverage renewed, according to KFF’s analysis of the outcomes of the Medicaid unwinding, which nearly all states have now completed.Despite these millions of disenrollments, 10 million more people are currently enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) nationally than at the start of the pandemic. Most states ended the unwinding with higher total Medicaid and CHIP enrollment than they began with in February 2020, including seven states where enrollment levels were at least 30% higher.During the COVID-19 pandemic, states kept people continuously enrolled in Medicaid in exchange for enhanced federal funding, leading to record growth in Medicaid enrollment. After the continuous enrollment policy ended on March 31, 2023 and under the process referred to as “unwinding,” states were required to complete eligibility renewals for all Medicaid enrollees.There have always been people eligible for Medicaid but not enrolled, as well as people who get dropped from Medicaid for failing to complete regular renewal processes. During the unwinding period, many states took steps to improve their renewal systems, leading to fewer people getting dropped even though they remain eligible. Five states — Missouri, Nebraska, North Carolina, Oklahoma, and South Dakota – have also adopted Medicaid expansion since the onset of the pandemic, and several states expanded eligibility for other groups, including children. The net effect is that Medicaid enrollment is higher than it was before the pandemic.However, enrollment among children has nearly returned to pre-pandemic levels (at only five percent higher.) Twelve states saw drops in child enrollment and three states saw enrollment fall for both children and adults relative to pre-pandemic levels.

Because Medicaid eligibility levels are more generous for children, these drops in child enrollment – coupled with an increase in the 2023 child uninsured rate – suggest some children may have lost coverage despite being eligible.Overall, 31% of people whose Medicaid coverage was redetermined during the unwinding were disenrolled, with wide differences across states. Five states had disenrollment rates of more than 50% (Montana, Utah, Idaho, Oklahoma, and Texas), while five states had rates under 20% (North Carolina, Maine, Oregon, California, and Connecticut).

This analysis marks the end of KFF’s independent effort to monitor the Medicaid unwinding using state and federal data. Going forward, the KFF Medicaid Enrollment and Unwinding Tracker will use data from the Centers for Medicare and Medicaid Services to track monthly Medicaid enrollment.

In April 2023, states began the process of unwinding the Medicaid continuous enrollment provision, a pandemic-era policy that protected Medicaid coverage for millions of enrollees. During the unwinding, states redetermined eligibility for everyone on the program and disenrolled those who were no longer eligible or who did not complete the renewal process. Before the start of the coronavirus pandemic in February 2020, there were 71 million people enrolled in Medicaid and CHIP. After the three-year pause in disenrollments, that number grew to a record high of 94 million people by April 2023, the month after the end of continuous enrollment. From the outset of the unwinding, there were major questions related to how many people would be disenrolled versus retain coverage and how that would affect overall Medicaid enrollment. Now that nearly all states have completed the unwinding of the Medicaid continuous enrollment provision, it is possible to take stock of overall renewal outcomes as well as where Medicaid enrollment stands and how current enrollment compares to pre-pandemic levels, nationally and across states. The Medicaid and CHIP enrollment data show more recent changes in enrollment that are not reflected in national survey data that report the overall uninsured rate in 2023 did not change from 2022, although there was an increase in the uninsured rate for children in 2023.

Using data from the KFF Medicaid Enrollment and Unwinding Tracker, this analysis reports data on unwinding renewal outcomes through June 2024 and examines Medicaid enrollment changes from February 2020 through May 2024, the most recent federal enrollment data available, nationally and across states. While the available data provide a nearly complete picture of renewals and disenrollments during the unwinding period, some data are preliminary with cases still pending in some states. These data mark the end of KFF’s independent effort to use state and federal data to monitor the Medicaid unwinding. Going forward, KFF will continue to track monthly Medicaid enrollment data reported by the Centers for Medicare and Medicaid Services (CMS).

Key Takeaways

• During the unwinding of the Medicaid continuous enrollment provision, over 25 million people were disenrolled and over 56 million had their coverage renewed. Overall, 31% of people whose coverage was redetermined during the unwinding were disenrolled, but that share ranged widely across states. For example, five states—Montana, Utah, Idaho, Oklahoma, and Texas—have disenrollment rates over 50%, while five states—North Carolina, Maine, Oregon, California, and Connecticut—have disenrollment rates under 20%.
• Despite millions of disenrollments during the unwinding, nationally, nearly 10 million more people are currently enrolled in Medicaid/CHIP than at the start of the pandemic. While enrollment among adults is over 20% higher than in February 2020, child enrollment has nearly returned to pre-pandemic levels and is only 5% higher.
• Several factors likely explain the net growth in Medicaid enrollment. The pandemic may have encouraged some people who were previously eligible for Medicaid but not enrolled to newly enroll, and during the unwinding, many states took steps to improve their renewal processes to reduce the number of people who were disenrolled despite remaining eligible. In addition, several states expanded eligibility for certain groups, including five states that adopted Medicaid expansion since the onset of the pandemic.
• Similar to the national trend, Medicaid/CHIP enrollment in most states is higher than it was in February 2020; however, total Medicaid/CHIP enrollment has fallen below pre-pandemic enrollment in three states, Montana, Colorado, and Arkansas, and child enrollment is lower in 12 states.

A look back on both the period of continuous enrollment and the unwinding period provides numerous potential lessons for Medicaid policy:

The growth in Medicaid enrollment during the pandemic demonstrated that continuous enrollment can stabilize coverage by reducing churn in the program that occurs when eligible people are disenrolled and then reenroll within a short period of time. Beginning January 2024, states are required to provide 12 months of continuous eligibility for children (previously 12-month continuous eligibility for children was optional for states). Many states are expanding on that policy to provide multi-year continuous eligibility for young children, and in some cases, two-year eligibility for older children and adults even though these policies will likely increase state and federal Medicaid spending.

At the same time, providing continuous coverage increases spending and results in people being enrolled who are not necessarily eligible based on their current circumstances. Federal Medicaid spending increased with rising enrollment during the pandemic, but enhanced federal matching payments to states stabilized state Medicaid costs despite large gains in enrollment.

In addition, streamlining renewal policies and procedures, particularly increasing ex parte or automated renewal rates, can improve coverage retention, but eligibility system capacity and functionality also plays a role.

And, finally, having timely and reliable data on renewal outcomes and enrollment enables closer monitoring of state Medicaid programs to identify problems but also to inform the strategies and flexibilities that can help states improve their processes. In May, CMS extended monthly reporting of renewal outcomes data required during the unwinding period to allow for continued monitoring of state programs.

Renewal Outcomes During the Unwinding

At the end of the unwinding of the Medicaid continuous enrollment provision in most states, over 56 million people had their coverage renewed and over 25 million people have been disenrolled (Figure 1). Although some cases remain pending across states, the overall disenrollment rate during the unwinding was 31%. This rate is somewhat higher than KFF and other groups had estimated before the unwinding began and contributed to more people being disenrolled during the unwinding than had been predicted. Among those who were disenrolled, 69% were terminated for paperwork or procedural reasons. Despite efforts by states to reduce the procedural disenrollment rate by conducting additional outreach or pausing disenrollments altogether, the rate remained high throughout the unwinding. In a more positive development, among those who retained coverage, over six in ten (61%) were renewed through ex parte, or automated processes. These automated renewals reduce the paperwork burden on both enrollees and state workers and make it easier for eligible individuals to retain coverage.

There is significant variation in renewal outcome metrics across states (Figure 1). For example, five states—Montana, Utah, Idaho, Oklahoma, and Texas—have disenrollment rates over 50%, with Montana the highest at 57%, while five states—North Carolina, Maine, Oregon, California, and Connecticut—have disenrollment rates under 20%. The differences result from a variety of factors, including state renewal policies and procedures, system capacity, and the extent to which states adopted flexibilities designed to maintain coverage for eligible enrollees. The share of renewals completed on an ex parte basis may also play a role. The ex parte renewal rates range from a high of 90% or more in Arizona, North Carolina, and Rhode Island to a low of 11% or less in Pennsylvania and Texas.

National Medicaid Enrollment Trends

As of May 2024, 81 million people were enrolled in Medicaid, an increase of about 10 million compared to pre-pandemic enrollment (Figure 2). During the pandemic, Medicaid enrollment increased by 32% or 23 million people. Since the start of the unwinding, enrollment has dropped by about 13 million, wiping out over half of the pandemic-era enrollment gains. As a result, enrollment remains about 13% higher than it was before the start of the pandemic.

Adult enrollment in Medicaid/CHIP remains well above pre-pandemic enrollment; however, enrollment among children has nearly returned to pre-pandemic levels. While adult enrollment is still over 20% above enrollment in February 2020, child enrollment is only about 5% higher. Adults experienced much higher enrollment growth during the pandemic than children. From February 2020 to April 2023, enrollment among adults grew by 45% while child enrollment increased by a more modest 20%. With the downturn in the economy in the early months of the pandemic, more adults enrolled in Medicaid and then were not disenrolled even if their circumstances subsequently changed. Additionally, several states adopted Medicaid expansion, increasing eligibility for adults, either just before or during the pandemic, including Utah and Nebraska in 2020, Missouri and Oklahoma in 2021, and North Carolina and South Dakota in 2023. Although the rate of enrollment decline has been steeper for adults during the unwinding period compared to children, enrollment gains for adults remain higher than those for children.

Medicaid Enrollment Trends Across States

During the unwinding, Medicaid/CHIP enrollment declined in all but two states—North Carolina and Oregon (Figure 4). While enrollment dropped about 14% nationally from March 2023 to May 2024, across states where enrollment declined, the drop varied widely from 2% in Maine to over 30% in Montana, Utah and Colorado. In most states, the net decrease in enrollment was higher for adults than children, but, in general, states with the largest net decline in enrollment for adults also experienced the largest net decline in child enrollment.

Compared to pre-pandemic levels, total Medicaid/CHIP enrollment remains higher in all but four states, and in seven states enrollment is 30% or more higher (Figure 5). Enrollment has dropped below pre-pandemic levels by 10% in Colorado, 9% in Montana, 2% in Arkansas, less than 1% in Tennessee, and remains essentially flat in Iowa. In these states, relatively moderate enrollment growth during the pandemic was offset by high disenrollment rates during the unwinding, though it is unclear what factors drove the higher disenrollment rates. In contrast, enrollment is 52% higher in Missouri and 50% higher in North Carolina. Among the ten states with the largest net increase in enrollment from February 2020 to May 2024, the increase has been driven by eligibility expansions during the unwinding in five of the states—the adoption of Medicaid expansion in Missouri, Nebraska, North Carolina, and Oklahoma, and a large increase in the eligibility level for children in Maine. The remaining five states—Hawaii, Indiana, Nevada, Oregon, and Virginia—all experienced large enrollment increases during the pandemic and retained much of the increased enrollment through the unwinding.

Children’s enrollment is below the pre-pandemic levels in 12 states as of May 2024, while adult enrollment is below pre-pandemic levels in four states. Enrollment in Medicaid/CHIP among children is down over 14% in Montana, between 6% and 10% in Colorado, Idaho, and Utah, and 3% or less in the remaining eight states. Enrollment is below pre-pandemic levels for both children and adults in Montana, Colorado, and Arkansas. In Tennessee, adult enrollment dropped below pre-pandemic enrollment, but child enrollment is slightly above the earlier level. Generally, it was expected that a greater share of children than adults would remain eligible and enrolled. However, the drop in child enrollment below pre-pandemic levels in so many states coupled with an increase in the child uninsured rate in 2023 suggests that that some children may have lost coverage despite still being eligible.

Allowing Medicare to negotiate drug prices on behalf of older Americans remains broadly popular across partisans, though many voters are unaware of the new law and the billions of dollars it is expected to save in 2026, a new KFF Health Tracking Poll finds.A large majority (85%) of voters say they support allowing the federal government to negotiate the price of some prescription drugs for people with Medicare. This includes at least three quarters of Republican (77%), independent (89%) and Democratic (92%) voters.

The Inflation Reduction Act of 2022 authorized such negotiations, and the Biden administration recently completed the first round of negotiations on 10 drugs, resulting in an estimated $1.5 billion in lower out-of-pocket costs for Medicare beneficiaries in 2026.The poll shows that nearly two thirds (65%) of voters are unaware or unsure that there is a law allowing Medicare drug-price negotiations. The share (62%) is similar among older voters (ages 65+) who are generally covered by Medicare.A large majority (75%) of voters also say they have not heard much about the savings resulting from the first round of price negotiations, including almost half (45%) who say they have heard “nothing at all.” One in four say they have heard “a lot” (4%) or “some” (21%) about the savings. Older voters are somewhat more likely to have heard either “a lot” (7%) or “some” (26%) about the savings.Other findings include:

• Most (55%) voters ages 65 and older expect that Medicare drug-price negotiations will lower their own prescription costs, with 43% saying it will not have any impact. Older Democratic and Democratic-leaning independent voters are more likely than older Republicans and Republican-leaning independent voters to expect savings (64% vs. 45%). 

• Minorities of voters are aware of other Medicare drug-price provisions in the Inflation Reduction Act, including the $35 cap on out-of-pocket costs for insulin (40%) and limiting annual out-of-pocket prescription drug costs (27%). Older voters are more likely than younger voters to know about both of these provisions. 
• While the Inflation Reduction Act was enacted under President Biden without any Republican support in Congress, partisans are divided on who deserves credit for the law’s Medicare drug price provisions. Substantial shares of GOP voters say that Republicans in Congress (54%) and President Trump (39%) had either a “major” or “minor” role in enacting those provisions. Larger shares of Democratic voters say that Democrats in Congress (80%), President Biden (81%), and Vice President Harris (69%) had a role. 
• Most voters say they would be in favor of extending Medicare’s $35 cap on monthly insulin costs (77%) and the $2,000 limit on out-of-pocket drug spending (69%) beyond people with Medicare, as Vice President Harris has proposed. Majorities of Democrats, Republicans and independent voters support extending each of the two provisions. 

Designed and analyzed by public opinion researchers at KFF, the survey was conducted August 26-Sept. 4, 2024, online and by telephone among a nationally representative sample of 1,312 U.S. adults, including 1,084 registered voters, in English and in Spanish. The margin of sampling error is plus or minus 4 percentage points for the full sample and among registered voters. For results based on other subgroups, the margin of sampling error may be higher.