An updated issue brief looks at the drivers of health spending in the U.S. and key differences between the U.S. and other large, wealthy nations. The analysis finds that people in the U.S. spent $5,683 more per person on health care compared to those in similarly large and wealthy countries. Almost 80% of the difference in spending came from inpatient and outpatient care costs. Many retail prescription drugs also cost more in the U.S. In 2021, the U.S. spent $1,635 per capita on prescription drugs, including over-the counter drugs, while comparable countries spent $944 on average

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

A new KFF analysis shows that the share of young adults (ages 18 to 26) receiving mental health treatment rose by 45% between 2019 and 2022 – a steeper increase than in any other age group.

More than 1 in 4 young adults (26%) received counseling and/or medication for mental health concerns in 2022, up from 18% three years earlier, according to the analysis of the most up-to-date National Health Interview Survey (NHIS) data available.  That was a higher share than among adults in any other age group in 2022.

While other age groups experienced an increase in the share receiving treatment over the period as well, the increase was smaller: 29% for adults ages 27-50, 13% for adults ages 51-64, and 1% for adults 65 and above.

The spike in utilization among young adults roughly coincided with the onset and most challenging years of the COVID-19 pandemic – when school and work were significantly disrupted – although utilization of mental health services had been increasing even before the pandemic. Even so, research shows that among young adults with mental health conditions, many still report not receiving treatment.

Overall, 23% of adults received mental health treatment in 2022, up from 19% in 2019, the analysis showed. Specifically, the share of all adults saying they received mental health counseling rose from 10% in 2019 to 13% in 2022. At the same time, the share of adults reporting they took prescription medication for mental health conditions increased from 16% to 19%.

The analysis shows that women were nearly twice as likely as men to report receiving mental health treatment in the past year (29% vs. 17% in 2022). Other research suggests that men may be less likely to seek mental health care than women, and they are more likely to be uninsured and less likely to report a usual source of health care.

Other key takeaways include:

• Across racial and ethnic groups, the share of people who said they received mental health treatment in 2022 was highest among White adults (28%) and lowest among Asian adults (9%). That compared to 16% each among Hispanic adults and Black adults.
• Adults with insurance coverage are more likely to report receiving mental health care in the past year than adults without insurance coverage (25% vs. 11% in 2022).

Many people in the United States experience mental health conditions, which raises questions about mental health service utilization patterns and what barriers exist with connecting people to services. Prior research suggests that mental health service utilization increased over time. This analysis explores more recent data, from 2019 to 2022, to understand the latest trends in utilization of mental health services and how it differs by demographics and insured status. In this analysis, receipt of mental health care is measured as the share of people who say they received mental health counseling and/or prescription medication for mental health concerns in the last year. Estimates shown are KFF analyses of National Health Interview Survey (NHIS) data among adults in the U.S. from 2019 to 2022.

In 2022, 23% of adults received mental health treatment, up from 19% in 2019 (Figure 1). Specifically, the share of adults saying they received mental health counseling in the past year increased from 10% in 2019 to 13% in 2022. Similarly, the share of adults reporting they took prescription medication for mental health conditions increased from 16% to 19% during the same period. Receipt of prescription medication remained consistently higher than counseling (19% vs. 13%, respectively, in 2022).

Compared to older adults, young adults (ages 18-26) were more likely to receive mental health treatment and experienced the highest increase in receipt of treatment over time. In 2022, 26% of young adults reported receiving counseling and/or prescription medications for mental health conditions in the past year, representing a significantly higher share compared to all other adults (ages 27 and above) (Figure 2).

Young adults also experienced the largest percent increase in the share of adults receiving mental health treatment from 2019 to 2022 (45%), followed by adults ages 27-50 (29%), 51-64 (13%), and 65 and above (1%) (Figure 2). Although receipt of mental health services has increased among young adults in recent years, other KFF analyses found that leading up to the pandemic, many young adults with mental health conditions did not receive treatment. The lack of treatment among this population may be linked to costs, transitioning from pediatric to adult health care, and difficulties accessing mental health services in college settings.

Women are nearly twice as likely to report receiving mental health treatment in the past year compared to men. In 2022, 29% of women reported receiving mental health services, compared to 17% of men (Figure 3). Research suggests men may be less likely to seek mental health care than women. Men are also more likely to be uninsured and less likely to report a usual source of health care. Separately, women are more likely than men to report experiencing mental health disorders, including serious mental illness.

Across racial and ethnic groups, past year receipt of mental health treatment was highest among White adults and lowest among Asian adults. In 2022, 28% of White adults reported receiving counseling and/or prescription medication for mental health conditions in the past year, compared to 16% of Hispanic and Black adults and 9% of Asian adults. A recent KFF poll found that, compared to their White peers, Hispanic, Black, and Asian adults disproportionately report challenges with mental health care utilization, including finding a provider who can understand their background and experiences, lack of information, and stigma or embarrassment. Additionally, the lack of a diverse mental health care workforce, absence of culturally informed treatment options, and stereotypes and discrimination associated with poor mental health may also contribute to limited mental health treatment among Black and Asian adults. Specifically among Asian people, cultural attitudes towards mental health are a factor that may lead to both lower reporting of mental health concerns and lower service utilization.

Adults with insurance coverage are more likely to report past year receipt of mental health care than adults without insurance coverage (25% vs. 11% in 2022, Figure 5). Despite higher utilization of mental health care over time – driven by insured adults – challenges remain with accessing services. For instance, KFF’s 2023 Consumer Survey found that 43% of insured adults with mental health concerns said there was a time in the past year when they did not get the mental health treatment they thought they needed, and 45% gave their insurance a negative rating for the availability of mental health providers. Further, KFF’s 2023 Employer Health Benefits Survey found that among employers offering health benefits, a higher share reported having a sufficient number of primary care providers in their plan’s networks (91%) compared to those who reported having a sufficient number of behavioral health care providers (67%).

The Inflation Reduction Act of 2022 includes several provisions to lower prescription drug costs for people with Medicare and reduce drug spending by the federal government, including several changes to the Part D benefit. These changes, including a new $2,000 cap on out-of-pocket drug spending, will help to lower out-of-pocket costs for Part D enrollees but could also make it harder for some Part D plan sponsors to offer low-priced coverage, particularly sponsors of stand-alone prescription drug plans (PDPs).

In anticipation of potential premium increases by Part D sponsors to cover higher costs associated with a more generous Part D drug benefit, the Inflation Reduction Act included a provision designed to help limit annual premium increases. Specifically, the law caps growth in the base beneficiary premium to no more than 6% above the prior year’s amount, though it is important to note that the base premium is not the same as the individual plan-level premiums charged by Part D sponsors and paid by Part D enrollees. In addition, the Centers for Medicare & Medicaid Services (CMS) made changes to the Part D payment methodology for 2025 to better reflect expected increases in plan liability for the redesigned Part D benefit, with the goal of enhancing market stability. CMS has also announced a new voluntary demonstration to provide additional premium stabilization and enhanced protection against the risk of losses to stand-alone PDPs (see details below).

These FAQs provide context for understanding Medicare Part D premiums in 2025 and changes in recent years. While the impact of the Part D benefit redesign changes on the 2025 Part D market is unknown at this time, premiums for individual Part D plans are likely to continue to vary and annual plan-level premium increases may be higher or lower than 6% for 2025, as they were for 2024. The fall open enrollment period will present all Part D enrollees with the opportunity to evaluate their coverage and determine whether there are lower-cost plan options that meet their needs.

Key Takeaways

• Changes to the Part D benefit in the Inflation Reduction Act will mean lower out-of-pocket costs for Part D enrollees but higher costs for Part D plans overall, leading to concerns about possible premium increases.
• CMS is taking steps to mitigate potential premium increases through a new demonstration program for stand-alone drug plans, as well as payment changes designed to bring greater stability to the Part D market in 2025.
• The Inflation Reduction Act includes a provision to cap growth in the base beneficiary premium to 6%. For 2025, the base premium is $36.78, an increase of $2.08 or 6% over the 2024 base premium. Although this 6% cap doesn’t apply to the individual premiums that plans charge, it does help to limit premium increases.
• Actual Part D plan premiums for 2025 are not yet known and will be announced in September, but premiums are expected to vary, with lower monthly premiums for Medicare Advantage drug plans than stand-alone drug plans, on average, as in 2024. The annual open enrollment period, which runs from October 15 to December 7, presents an opportunity for Part D enrollees to compare plans and shop for lower-priced coverage that meets their needs.

How is the Part D benefit changing for 2025?

The Inflation Reduction Act includes a number of changes to the Medicare Part D drug benefit, including a new $2,000 cap on out-of-pocket drug spending in 2025 for enrollees in Medicare Part D plans. It also requires Part D plans and drug manufacturers to pay a greater share of costs for Part D enrollees with drug costs in the catastrophic coverage phase (above the $2,000 spending cap) and reduces Medicare’s reinsurance liability. The law also eliminates the coverage gap phase as of 2025, where enrollees are currently responsible for paying 25% of their drug costs, drug manufacturers provide a 70% price discount on brand-name drugs, and plans pay 5% of costs.

As of 2025, once enrollees have met their deductible (if their plan includes one), they will enter the initial coverage phase, where they will face cost sharing of 25% under the standard benefit (as in 2024), manufacturers will provide a 10% price discount, and Part D plans will pay 65% (Figure 1). Once enrollees reach the out-of-pocket spending cap and enter the catastrophic coverage phase, plans will be required to pay 60% of drug costs, up from 20% in 2024, and drug manufacturers will be required to provide a 20% price discount on brand-name drugs. Medicare’s share of total costs in the catastrophic phase will decrease from 80% to 20% for brand-name drugs and from 80% to 40% for generic drugs.

Although Part D plans will be taking on additional liability for high drug costs in 2025, Medicare will continue to limit their liability for higher-than-expected drug costs through risk corridors, a risk sharing mechanism that has been in place since the Part D program started in 2006. In addition, CMS is launching a new voluntary demonstration to provide enhanced risk-corridor protection against overall losses for participating stand-alone PDPs to help stabilize the market (see details below).

What is known about Part D premiums for 2025?

CMS announced the Part D base beneficiary premium for 2025 on July 29, 2024 (this announcement typically occurs at the end of July each year). For 2025, the base beneficiary premium is $36.78, an increase of $2.08, or 6%, over the 2024 base premium of $34.70. A provision in the Inflation Reduction Act capped annual growth in the base beneficiary premium to 6% over the prior year’s amount (see details below).

The base premium is calculated as a share of average plan bids for basic Part D benefits submitted by both stand-alone PDPs and Medicare Advantage drug plans (MA-PDs). All Part D plans submit a bid for basic benefits, while plans that offer enhanced benefits, such as a lower Part D deductible, also report the portion of their bid that is for basic versus enhanced benefits. (In 2024, most Part D enrollees were in enhanced plans: 72% of all Part D enrollees, including 79% of MA-PD enrollees and 62% of PDP enrollees). Each year, CMS averages standardized bids submitted by PDPs and MA-PDs to cover basic Part D benefits and calculates the National Average Monthly Bid Amount, or NAMBA. The calculation of the base beneficiary premium is based on the national average bid adjusted for individual reinsurance subsidies. Because the base premium is an average across both types of plans and reflects the cost of basic benefits only, this amount does not equal what a Part D enrollee will pay for coverage in any given Part D plan.

Actual premiums for Part D plans available in 2025 will be released in September, as they are every year, just prior to the October 1 start date of marketing for the coming plan year and the open enrollment period that runs from October 15 to December 7.

How will the new CMS demonstration help to stabilize the Part D market for 2025?

CMS has announced new premium stabilization measures for stand-alone PDPs as part of a voluntary Section 402 demonstration program that will be in effect for 2025 and two additional years (though the exact parameters may vary beyond 2025). Because CMS observed more variation in plan bids for 2025 among PDPs than MA-PDs, the new Part D Premium Stabilization Demonstration is targeted exclusively to PDPs. CMS’s rationale for this demonstration is to stabilize the PDP market in the initial transition years of the Inflation Reduction Act’s Part D benefit improvements, and to test whether the premium changes and revised risk corridors “increase the efficiency and economy” of services as the law’s Part D benefit changes are fully implemented. Similar Section 402 demonstrations were conducted under the George W. Bush Administration in the early years of Part D as the program was being rolled out.

The Part D Premium Stabilization Demonstration has three components for PDPs that choose to participate:

• Lowers the base beneficiary premium by $15 (or less if a $15 reduction would result in a plan premium of less than $0).
• Limits total Part D premium increases to $35 between 2024 and 2025 (applied after taking into account the $15 reduction in the base beneficiary premium).
• Narrows the upper thresholds of the risk corridors to reduce the range of spending where PDPs bear full risk for actual costs higher than their bids and increases the government’s risk sharing for a portion of plan losses from 80% to 90% (Figure 2).

What is the Inflation Reduction Act’s Part D premium stabilization provision and what impact has it had to date?

Beginning in 2024, the premium stabilization provision of the Inflation Reduction Act caps annual growth in the Part D base beneficiary premium at 6%. For 2024, the first year the premium stabilization provision was in effect, the Part D base beneficiary premium was $34.70, a 6% increase over the 2023 amount of $32.74 (Figure 3). Without the premium stabilization provision, the 2024 base beneficiary premium would have been $39.35, an increase of 20%, reflecting a higher average monthly bid amount for basic Part D coverage in 2024 ($68.28) than in 2023 ($34.71).

For 2025, the Part D base beneficiary premium is $36.78, capped at a 6% increase over the 2024 amount. Without premium stabilization, the 2025 base premium would have been $55.98, 42% higher than the 2024 unadjusted base premium (61% higher than the base premium with the 6% cap in 2024). Between 2024 and 2025, the average monthly bid amount for basic benefits increased from $64.28 to $179.45. (See below for examples of how the 6% cap on the base premium helps to limit growth in premiums paid by enrollees for two hypothetical plans.)

What other changes has CMS adopted to help to limit Part D premium increases for 2025?

In addition to the premium stabilization measures described above, CMS has also made changes to its plan payment methodologies for the 2025 plan year. While technical in nature, these changes are designed to enhance market stability through an improved payment methodology that accounts for the substantial changes to the Part D benefit for 2025.

• Updates to the Part D risk adjustment model: The Part D risk adjustment model predicts plan liability for prescription drugs. The model is used to determine the amount of “direct subsidy” prospective payments that Part D plans receive from the federal government, which are adjusted for the health status of a plan’s enrollees. Enrollees with higher risk scores (which vary above and below an average of 1.0) translate to higher expected plan costs and higher subsidy payments. For 2025, CMS took steps to improve the predictive ability of the Part D risk adjustment model, including by recalibrating the model based on more current diagnosis and spending data than used in previous years.
• Using different normalization factors for MA-PDs and PDPs: For individual Part D enrollees, risk scores are calculated based on individual demographic and disease factors, and then adjustments are applied, including a “normalization factor.” New for 2025, CMS is applying different normalization factors for MA-PDs and PDPs, which will have the effect of increasing PDP risk scores relative to what they would have been otherwise. Historically, due to differences in coding and utilization patterns across both types of plans, the Part D risk adjustment model has underpredicted costs for PDP plans and overpredicted costs for MA-PD plans, which has had the effect of increasing standardized plan bids (and premiums) for PDPs relative to MA-PDs. Using separate normalization factors is expected to increase PDP risk scores, which would lead to higher direct subsidy payments, which could mitigate potential premium increases to help stabilize the PDP market. Because MA-PD sponsors can use rebate dollars from Medicare payments to lower or eliminate their Part D premiums, most MA-PD enrollees pay no premium for their Part D drug coverage (see details below).

What factors contributed to the increase in plan bids for basic benefits since 2023?

For 2025, the new $2,000 out-of-pocket spending cap and the increase in Part D plan liability for drug costs incurred by enrollees above the cap, combined with the reduction in Medicare reinsurance, as explained above, are factors in the higher national average monthly plan bid. CMS has emphasized that while the NAMBA increased substantially for 2025, this will be accompanied by substantially higher upfront payments from the government to plans in the form of direct subsidies for basic benefits covered by the plan – a shift from previous years when reinsurance payments accounted for a much larger share of Part D spending than direct subsidy payments. CMS estimates that the average direct subsidy payment will be $142.67, or 80% of the national average bid amount of $179.45.

For 2024, part of the explanation for the higher national average bid for basic benefits was the elimination of Part D enrollees’ 5% coinsurance requirement for drug costs in the catastrophic coverage phase and the increase in plans’ share of these costs from 15% to 20%. Another factor was a revision to the definition of Part D’s “negotiated price” that took effect in 2024 (not to be confused with the new drug price negotiation program established by the Inflation Reduction Act). The definition of negotiated price has been in place since the start of Part D, and it matters because this is the price upon which beneficiary cost sharing is based at the point of sale, which is particularly relevant when enrollees face a coinsurance requirement. Under the change, plans are now required to pass along all price concessions they receive from pharmacies, which help to lower the plan’s total costs, to enrollees at the point of sale. Enrollees will benefit from this change in the form of lower out-of-pocket drug costs, but plans were expected to face higher costs and lower revenues.

What do Part D premiums look like in 2024?

While the impact of the Part D benefit redesign changes on the 2025 Part D market is currently unknown, premiums for individual Part D plans are likely to continue to vary in 2025, as they do in 2024 – ranging from $0 to $100 per month or more. This is in part why Part D enrollees are encouraged to shop for plans during the annual open enrollment period in the fall.

For 2024, the average monthly premium for Part D coverage is $25, including premiums for both Medicare Advantage drug plans (MA-PDs) and PDPs. The average monthly premium for drug coverage in MA-PDs ($9) is substantially lower than in PDPs ($43). In 2024, 57% of all Part D enrollees are in MA-PDs in 2024 and 43% are in stand-alone prescription drug plans (PDPs).

The lower MA-PD average premium is heavily weighted by the predominance of zero-premium plans in the MA-PD market, because, as noted above, MA-PD sponsors can use rebate dollars from Medicare payments to lower or eliminate their Part D premiums. For 2024, all Medicare beneficiaries had access to zero-premium MA-PD plans – 27 on average – whereas only 1 PDP was available for zero premium for non-LIS enrollees in only 14 out of 34 PDP regions.

Even with changes to the Part D benefit between 2023 and 2024 that increased plan liability, the average monthly premium for Part D coverage across both plan types combined was the same in both years ($25) (Figure 4). The average MA-PD premium decreased by $1 (from $10 to $9), while the average PDP premium increased by $3 (from $40 to $43).

The $43 average PDP premium is based on enrollment in March 2024 after the end of open enrollment. This amount is lower than the estimated $48 premium for 2024, which was calculated in the fall of 2023 before open enrollment for 2024 and did not account for plan switching by current enrollees or plan choices by new enrollees during the open enrollment period. The fact that the actual average PDP premium for 2024 is lower than the estimated premium indicates that some PDP enrollees opted for lower-premium plans during open enrollment.

What share of Part D enrollees pay no premium for drug coverage?

Overall, nearly half of the 30.1 million Part D enrollees who are not receiving Part D low-income subsidies (LIS), or 14.3 million enrollees, pay no premium for their drug coverage in 2024 (Figure 5). The share of Part D enrollees paying no premium is heavily weighted by MA-PD enrollees. In 2024, three-quarters of MA-PD enrollees without LIS pay no premium for their drug coverage compared to 13% of PDP enrollees.

How does the Inflation Reduction Act premium stabilization provision help to limit growth in Part D premiums?

The premium for an individual plan is calculated as the base premium plus the difference between the plan’s bid and the national average bid (the NAMBA). Examples with two hypothetical plans illustrate how the 6% cap on growth in the base premium limits premium growth for an individual plan (Table 1).

For both plans, the 6% premium stabilization cap mitigates the increase in plan premiums between 2023 and 2024. For Plan A, with the 6% cap in effect, the premium increased by 10%, but without the 6% stabilization cap, the premium would have increased by 31%. Similarly, for Plan B, the 6% cap limits premium growth to 19%, compared to a 32% increase without the cap.

Approximately 1 in 5 teens in the United States experience symptoms of anxiety or depression and many youth experience bullying and violence, which can have adverse effects on their mental health. Schools can play a role in promoting mental health and connecting youth to treatment. One approach that many schools have implemented is social and emotional learning, which teaches skills such as emotional management, resilience, and relationship building. Social and emotional learning in schools has received more attention in recent years. For instance, the Surgeon General’s 2021 Youth Mental Health Advisory recommended the expansion of social and emotional programs. Meanwhile, critics argue that these programs should be banned from schools, suggesting that they take away from academic instruction time and incorporate critical race theory.

Social and emotional learning programs focus on developing intrapersonal and interpersonal skills; however, specific program content and integration strategies can vary widely across schools. Goals, benchmarks, and guidelines for social and emotional learning programs in schools are typically developed at the state level. Individual schools may then implement social and emotional learning in a number of ways, including through academic instruction (e.g. group projects to encourage collaboration, or complex problem-solving to encourage persistence); through separate, dedicated time for social and emotional learning instruction; or through schoolwide measures (e.g. disciplinary methods that incorporate social and emotional learning competencies). Regardless of how social and emotional learning is integrated, the content typically focuses on intrapersonal and interpersonal skill building, including self-awareness, self-management, responsible decision making, social awareness, and relationship skills.

Sixty-three percent of public schools in the U.S. had a formal curriculum to support their students’ social and emotional skill development in the 2023-2024 school year (Figure 1). These curricula are more common in elementary schools (74%) compared to middle (58%) and high schools (43%). Additionally, among schools with a formal curriculum, 81% of teachers and 51% of non-teaching staff received training or professional development to implement their school’s curriculum.

Among schools with a social and emotional learning curriculum in the 2023-2024 school year, 72% found that the curriculum was moderately, very, or extremely effective in improving student outcomes. Social and emotional learning has been linked to positive outcomes for students, including fostering emotional intelligence, reducing emotional distress, fostering empathy, developing and maintaining peer relationships, and academic improvement. However, measuring outcomes of social and emotional learning programs can be difficult as implementation strategies and content may vary between programs.

Common barriers to implementing social and emotional learning curricula in schools include lack of funding and materials. Thirty-seven percent of public schools reported not having a formal curriculum for social and emotional skill development in the 2023-24 school year. Among these schools, a lack of time (46%), funding (37%), and materials and resources (34%) were the main reasons for not having a formal curriculum (Figure 2). Several funding opportunities to support social and emotional learning have opened in the last decade, including the Every Student Succeeds Act in 2015, and more recently, the American Rescue Plan Act (ARPA) in 2021, which required school districts to use a portion of funds to support students’ mental health needs. Analyses of how school districts planned to spend ARPA funds found that student social-emotional development was a priority, with many districts allocating some funds to social and emotional instruction materials and training. However, schools often have many competing budget priorities, such as providing funds to address staffing shortages and academic recovery in light of the pandemic, which may limit the amount of funds they have available for social and emotional learning.

As support for social and emotional learning in schools has grown in recent years, so has opposition. Opponents argue that social and emotional learning in schools can take away from academic instruction time; and, more recently, that it incorporates critical race theory and gender identity lessons. This has led to the introduction of several state bills – including Indiana, Iowa, Montana, North Dakota, Oklahoma, Maine, and New Hampshire – banning or limiting social and emotional learning in schools. Supporters, however, argue that social and emotional learning is an evidence-based approach that allows schools to focus on the “whole child”, leading to a wide array of positive outcomes, such as academic achievements, emotional intelligence, and growth opportunities for all students regardless of their backgrounds. This support was recently reflected in a bipartisan resolution designating a “National Social and Emotional Learning Week” which also received recognition from President Biden.

On July 16, 2022, the federally mandated crisis number, 988, became available to all landline and cell phone users at no charge. This three-digit number connects users–via phone, text, or chat–to a network of over 200 local and state-funded crisis call centers, providing access to the 988 Suicide & Crisis Lifeline for crisis counseling, resources, and referrals. Federal investments supported the launch and implementation of 988, but ongoing funding of local call centers, as well as the development of other core components of the behavioral health crisis continuum, largely falls to state and local governments.

Over half a million lives (500,399) were lost to suicide between 2012 to 2022, with suicide rates rising nationally and in most states over this period (Appendix Table 1). Reflecting rising suicide rates, 9 in 10 adults believe the United States is amid a mental health crisis. Firearms are the predominant suicide method, involved in over half of all suicides, and increases in firearm suicides drove the total suicides to a record high in 2022.

This brief examines 988 two years after implementation using the most recent data available through May 2024 from Lifeline, including: 988 performance metrics nationally and by state, state efforts to fund local 988 call centers, emerging policies and initiatives that may indicate future trends, and a look at data that may be helpful in ongoing monitoring and development of 988.

Key takeaways from this KFF analysis of Lifeline data include the following:

• Since launch in July 2022, 988 has received 10.8 million calls, texts, and chats. In May 2024, monthly contacts exceeded half a million, up about one-third from a year ago and 80% since May 2022. Despite increased demand for 988 services, national answer rates improved and wait times decreased, though some gains slipped in the second year.
• State-level call volume and in-state answer rates vary widely across states. Monthly call volume increased in all states—ranging from 25% to 185% since launch — and the most recent in-state answer rates range from 64% to 97% in May 2024.
• Ten states have added telecom fees to provide more sustainable funding for local 988 crisis call centers, which may help centers keep up with the rising call volumes.
• Developments in 988 policy and crisis service policy include potential changes in 988 routing (georouting), continued expansion of mobile crisis and short-term crisis stabilization facilities, enhanced technology and infrastructure to connect 988 with other crisis and emergency services, and growth of specialized services for certain populations.
• 988 metrics are available online through Lifeline, though these data tend to be somewhat limited. Some states are using dashboards to provide additional data that may help to inform efforts to address suicide rates in their state.

What do we know about 988 utilization and awareness?

Since launch in July 2022, 988 received nearly 10.8 million contacts, including 1.4 million to the Veteran’s Crisis Line (VCL), with the remaining contacts consisting of 6.4 million calls, 1.4 million chats, and 1.6 million texts. SAMHSA reports that over 10 million calls, texts and chats have been answered by crisis counselors since launch, including those to the VCL. Detailed data for the VCL is not publicly available, so the remainder of the brief will not include that data. Calls are the most common mode of 988 contact, accounting for about two-thirds (68%) of total contacts to 988. Text messages and chats make up the remaining one-third of total contacts, accounting for 17% and 15%, respectively. Lifeline metrics provide only a partial picture of total crisis hotline contacts, as fewer than half of all crisis call centers (about 200 of 544) participate in the Lifeline network.

988 contacts (calls, texts, and chats) exceeded half a million in May 2024, up about one-third from a year ago and 80% since May 2022. Text message volume saw the highest relative increase, growing more than 11-fold since launch, compared to nearly 2-fold for calls. In contrast, chat volume decreased, possibly because text communication via cell phone is preferred over browser-based chat (Figure 1).

Since launch, national answer rates improved and wait times fell, even with substantial rises in contact volume—though some gains slipped in year 2. Overall answer rates rose from 70% in May 2022 (before launch) to 89% two years later, and wait times fell from 2 minutes and 20 seconds to 1 minute and 31 seconds. While these do represent improvements since launch, they are somewhat lower than they stood at one year after 988’s launch—where answer rates were higher, at 93% and wait times were lower, at 35 seconds. The decline in some performance metrics in year 2 may be due to continued rise in 988 contacts (Table 1).

KFF polling indicates that public awareness of 988 is generally low, with 18% of adults reporting they have heard a lot or some about it. As of mid-2023, fewer than 2 in 10 adults reported familiarity with 988 and its services, though awareness may have increased since then. Despite generally low awareness, those with high psychological distress, adults who speak English very well, and White adults are more likely to report familiarity with 988. In contrast, awareness is lower among Black, Hispanic, and Asian adults and among those who do not speak English very well (Figure 2). Federal awareness campaigns set to launch in mid to late 2024, along with proposed legislation introduced to Congress late last year, aim to boost public awareness of 988 and its services. As knowledge of 988 rises, so could the demand for its services.

How does implementation vary by state?

Call volume increased in all states, with increases up to 185%. State-level data is available through Lifeline for calls to 988, but not for text or chat. Nationally, call volume rose by 95% from pre-launch to two years later, but this varied widely across states, from a low of 24% in Idaho to a high of 185% in Oklahoma. The variation in growth rates across states may be influenced by the development of 988 infrastructure and public awareness campaigns

Although nearly all states have maintained or improved their in-state answer rate since 988’s launch, answer rates continue to vary across states and range from 64 to 97% as of May 2024. 988 routes calls based on the caller’s area code to the nearest crisis center. An “in-state answer rate” measures the percentage of calls answered in the state that aligns with the caller’s area code. In May 2024, in-state answer rates ranged from a low of 64% in Nevada up to 97% in Mississippi, Montana, and Rhode Island. Calls not answered in-state are either transferred to one of Lifeline’s national backup centers or abandoned by their caller. Long wait times or local crisis center unavailability can lead to a call being redirected to national backup centers, where counselors will answer the crisis call, but may be less familiar with local resources. These calls count toward the national answer rate but not toward the answer rate of the state where the Lifeline backup center is located. Nationally, about 6% of state calls are transferred to a federal overflow facility and 10% are abandoned in-state, though these rates also vary by state. Per SAMHSA, calls may be abandoned by their user due to a technical reason (e.g. internet or mobile connection strength or service interruptions, etc.) or because the person seeking assistance ends the contact before a counselor answers, which could also happen for a range of reasons, such as they had to wait too long or decided they were not comfortable discussing their experience.

Ten states have added telecom fees to provide more sustainable funding for local 988 crisis call centers, which may help local crisis centers keep up with rising demand for the service. Although federal investments support 988 nationally and help to support state implementation, states are largely responsible for long-term funding of the local 988 crisis call centers, which have historically received minimal funding from the federal government. Under the National Suicide Hotline Designation Act of 2020, states can collect cell phone fees to help sustainably fund their local 988 call centers (similar to how 911 is funded). So far, ten states have enacted legislation to fund crisis services through telecom fees, including Virginia, Colorado, Washington, Nevada, Minnesota, California, Oregon, Delaware, Maryland, and most recently Vermont. Additionally, four other states have pending telecommunications fee legislation. Early adopters of telecom fees, such as Virginia and Washington, collected between $10.9 to $30.4 million in 988 telecom fees during FY 2022, according to an FCC report. Other sources of 988 funding include trust funds and general fund appropriations, and 5% crisis services set aside from mental health block grant funds. Insurer payments can help financially sustain 988 and other crisis services, with some states billing Medicaid or other payers and several states also passing laws requiring insurers to cover crisis care services.

What are new developments related to 988 and the crisis continuum, more broadly?

Proposals to improve 988 routing aim to mirror certain 911 standards, including georouting and requirements for cell phone carriers to route 988 calls during service interruptions. Currently, 988 routes calls based on the caller’s area code, which can be problematic for people with area codes not reflective of their current location, resulting in connections to distant crisis centers with counselors unfamiliar with the local resources near the caller. Unlike 911, which uses precise geolocation data, the proposed 988 georouting would direct calls to the nearest crisis center without disclosing the caller’s exact location, helping to address technical, privacy, and legal concerns. In April of this year, the Federal Communications Commission (FCC) issued a notice proposing rulemaking for wireless carriers to adopt 988 georouting and requested comments on extending this to text messages and specialized services like LGBTQ+ and Spanish services, which are not available at all local crisis center locations. Separate legislation proposed late last year aims to improve 988 access by requiring carriers to allow 988 calls during service disruptions and ensuring multi-line systems, such as those in hotels, recognize 988 calls directly without additional steps like dialing 9 first.

Similar to 988, mobile crisis units and short-term crisis stabilization facilities are core components of the behavioral health crisis continuum, though their development and availability varies across states. Mental health professionals staff these services and provide alternatives to emergency departments and law enforcement during mental health emergencies. States are at different stages of establishing mobile crisis and short-term crisis stabilization services, and some states have leveraged Medicaid and Medicaid-focused provisions in the American Rescue Plan Act to support mobile crisis development. Most states have some form of mobile crisis, but short-term crisis stabilization facilities are less common. Even among states that have mobile crisis units, these units are often not available 24/7 or statewide. Compared to 988, other components of the crisis response system have little federal coordination, which may result in more variation in their development and structure across states.

States are investing in technology to improve infrastructure and coordination across crisis services and other emergency and health services. For example, some states are developing infrastructure to enable coordination and call diversion for mental health calls from 911 to 988. However, technical and logistics challenges, such as the presence of multiple local 911 call centers per area code and the need to develop operational rules and agreements for each, have slowed progress. Other technological developments include service registries to track bed availability, facility capacity, and appointment scheduling. GPS-enabled mobile crisis dispatch systems and tools for crisis staff to view and schedule mental health appointments are also being developed. Recent CMS guidance clarifies how Medicaid may help support some of these efforts. Additionally, the federal government’s action plan, part of the HHS’s 2024 National Strategy for Suicide Prevention, proposes funding a mobile crisis locator for use by 988 crisis centers.

Specialized services to meet the unique needs of various populations, including LGBTQ people, Spanish speakers, American Indian and Alaska Native (AIAN) people, older adults, and others, are being developed at both federal and state levels. In March 2023, Lifeline expanded its LGBTQ+ services, providing 24/7 text and phone access to affirming counseling for those under age 25. This line accounted for nearly 10% of all 988 contacts over a four-month period, but had higher abandonment rates and longer wait times than the general 988 line. Additionally, 988 offers options to route Veterans, people who speak Spanish, and people who have difficulty hearing to specialized services. Certain states are building targeted services for older adults (staffed with older adult peer supports) and launching youth-specific initiatives, including mobile crisis services for youth. Efforts are being made to provide culturally competent services for AIAN populations and other racial and ethnic groups, to address the unique needs of rural and remote areas, and to support individuals with co-occurring mental health and substance use needs.

What data beyond Lifeline could help inform implementation and improvement efforts?

Additional state and national crisis center metrics may help inform the 988 implementation and future program improvements. Call volume, wait times, and other metrics from Lifeline provide some insights into accessibility and demand for 988, but they don’t tell the whole story. For example, without additional data, it’s not possible to answer questions about the conditions or circumstances that prompted the 988 calls, the resolution of these calls and whether they connected to additional crisis or outpatient services, and user experience across different demographics and geographies. Comprehensive metrics can help policymakers and researchers evaluate 988’s effectiveness, identify gaps, and develop targeted interventions. Table 2 lists metrics that could be helpful for understanding 988’s implementation.

Some states or crisis call centers already track and display detailed crisis metrics through regularly updated dashboards. These online dashboards display key metrics of crisis call data, refreshed at regular intervals. In Arizona, the Solari Crisis Response Network displays aggregate data for crisis call centers in two regions. Similarly, the University of Utah summarizes Utah’s crisis data in a dashboard and in crisis services annual reports (2021 and 2020). South Dakota’s only crisis line displays detailed aggregate data on a publicly accessible dashboard, including historical data and breakouts by age, race, and gender. Data presented on these dashboards are more detailed than Lifeline data, containing metrics on accessibility, referral source, reason for the call, and some outcomes, but many do not contain historical summaries. Wisconsin’s dashboard is an exception, as it provides monthly snapshots and downloadable historical summary data.

If you or someone you know is considering suicide, call or text the 988 Suicide & Crisis Lifeline at 988

Health care debt is a widespread problem in the United States, garnering the attention of some policymakers and emerging as a potential campaign issue. A 2022 KFF survey found that 2 in 5 US adults (41%) of all ages report some form of debt due to medical or dental bills for their own or someone else’s care. Nearly three-quarters of adults say they are worried about affording unexpected medical bills or the cost of health care services, higher than the shares who report worrying about affording other household expenses. The Medicare program, which provides health insurance coverage to 66 million people, most of whom are older adults ages 65 or older, helps to cover the cost of medical care for those who qualify, yet health care cost-related problems among Medicare-age adults are not uncommon and leave many exposed to debt, with potentially serious and long-lasting health and financial consequences.

Medicare offers coverage for a range of health care services, including hospitalizations, physician visits, prescription drugs, and post-acute care, but Medicare beneficiaries generally pay out-of-pocket for their monthly premiums and deductibles, cost-sharing for Medicare-covered services, and the cost of services not covered by Medicare, such as dental, vision, and hearing care and long-term services and supports. Medicare households also spend more on health care than other households and devote a larger share of their household budgets to medical costs and premiums. Health costs are a particular challenge for the millions of Medicare beneficiaries with limited income and savings to absorb unexpected health or other expenses. Finally, older adults are more likely than younger populations to have cognitive impairments such as Alzheimer’s Disease, which have been shown to contribute to a decline in credit scores and financial instability years before the condition is diagnosed.

This data note examines findings from the KFF Health Care Debt Survey to assess the prevalence, sources and consequences of health care debt among Medicare-age adults.

Key Takeaways

• More than one in five US adults ages 65 and older (22%) reported having some form of debt in 2022 as a result of medical or dental bills for their own or someone else’s care, which is half the share reported among adults ages 50-64 (44%).
• Among Medicare-age adults with health care debt, large shares say that some of the bills that caused their debt were due to routine health care services such as lab fees and diagnostic tests (49%), dental care (48%), and visits to the doctor (41%).
• Nearly three in ten Medicare-age adults with health care debt (29%) say their household has been contacted by a collection agency in the past five years as a result of medical or dental bills, while one in four (23%) say that health care debt has negatively affected their credit score.
• Three in five Medicare-age adults with health care debt (62%) say that they, or another member of their household, have delayed, skipped, or sought alternatives to needed health care or prescription medications due to costs in the past year.

In 2022, more than one in five US adults ages 65 and older (22%) had some form of debt as a result of medical or dental bills (Figure 1). This is roughly half the share found among adults ages 50 to 64 (44%), who are not yet eligible for Medicare based on age. Lower rates of health care debt among older adults are likely due, in part, to nearly universal Medicare coverage among people ages 65 and older. Additionally, most Medicare beneficiaries have some form of coverage that limits their cost-sharing expenses, such as Medicare Advantage, or supplemental coverage, such as Medicaid, retiree health benefits, or Medigap.

The rate of health care debt among people ages 65 and older is higher than reported by some others,  principally because of methodological differences in the way health care debt is defined. Surveys of health care debt in the US have commonly focused on unpaid medical bills, or bills which have been sent to collections, which may overlook the share of adults who pay off their health care bills by accumulating credit card debt, taking out loans, or borrowing from family and friends. For this reason, the KFF Health Care Debt Survey provides a broad measure of health care debt, which includes other types of debt incurred as a result of medical or dental bills, as well as debts owed for the care of someone else, such as a child, spouse, or parent.

Many older adults pay off their health care bills by accumulating credit card debt or debt from other sources (Figure 2). Roughly one in ten Medicare-age adults report having medical or dental bills that they are paying off over time directly to a provider (12%), put on a credit card and are paying off over time (11%), are past due or unable to be paid (8%), or have debts owed to a bank, collection agency or other lender as a result of loans used to pay off medical or dental bills (7%). A smaller share report debts owed to family and friends for money borrowed to pay off medical or dental bills (3%).

Roughly two in five Medicare-age adults with health care debt (39%) owe less than $1,000, including one in five (19%) who owe less than $500, but one in ten Medicare-age adults with health care debt (11%) owe $10,000 or more (data not shown). Even relatively small amounts of debt can contribute to a drop in credit ratings.

Sources of health care debt among older adults are varied, and include many routine health care needs (Figure 3). Nearly half of Medicare-age adults with health care debt say that some of the bills that caused their debt were due to lab fees and diagnostic tests (49%), dental care (48%), and visits to the doctor (41%). One in three (31%) attribute a portion of their debt to emergency care, and one in four (24%) to prescription drugs. Dental care is one of the leading causes of health care debt among Medicare-age adults, likely due to the fact that traditional Medicare does not offer coverage for dental care services. (Most Medicare Advantage plans include some dental care coverage, but the scope of coverage varies widely, and enrollees may still incur substantial out-of-pocket costs for these services.)

Just 6% of Medicare-age adults attribute a portion of their debt to bills for long-term care services and supports, such as the cost of nursing home care, assisted living or full or near full-time home health aides. These services are used extensively by a relatively small segment of the Medicare population but can be quite costly. For example, in 2023, the median annual cost of a private room in a nursing home was $116,800 and $288,288 for round-the-clock home health aide services. These costs far exceed the median income ($36,000 per person) and savings ($103,800 per person) of the average Medicare beneficiary in 2023. Medicare does not generally cover these services, placing them out of reach for many older adults and leaving some with substantial debt. (Survey findings may underrepresent the costs and associated debt incurred by people living in nursing homes, assisted living facilities and other institutional settings, though the survey does include debt associated with long-term services and supports if incurred by other family members.)

The financial consequences of health care debt may be lasting. Nearly three in ten Medicare-age adults with health care debt (29%) say their household has been contacted by a collection agency as a result of medical or dental bills, while one in four (23%) say that health care debt has negatively affected their credit score (Figure 4). For retirees with health care debt, these consequences may be difficult to reverse, and can make it more challenging to secure affordable credit in the future. The Consumer Financial Protection Bureau recently proposed a rule that would remove health care bills from most credit reports and prohibit lenders from making loan decisions based on medical information, with the goal of reducing the burden of health care debt for US adults and safeguarding against coercive credit reporting practices.

Two in five Medicare-age adults with health care debt report that they, or another member of their household, have cut back spending on household necessities (42%) or used up a large portion of their savings (39%) in the past five years as a result of their health care debt (Figure 5). One in three have taken money out of long-term savings accounts, such as a retirement account (34%) or increased their credit card debt for non-medical purchases (31%), and one in five have taken out a loan (21%) or skipped or delayed payment of other bills (18%). Sacrifices such as these can have serious consequences for financial stability and general wellbeing and may perpetuate the cycle of health care debt by leaving older adults with fewer resources for other needed health expenses.

Three in five Medicare-age adults with health care debt (62%) say that they, or another member of their household, have delayed, skipped, or sought alternatives to needed health care or prescription medications due to costs (Figure 6). Nearly half (48%) of Medicare-age adults with health care debt postponed getting health care they needed in the past year, while two in five (43%) relied on home remedies or over the counter drugs instead of going to the doctor, and one in three did not get a medical test or treatment recommended by a doctor (31%) or took less than the prescribed dose of a medication by skipping doses, cutting pills in half, or leaving the prescription unfilled (28%).

This fact sheet summarizes the major statutory requirements and policies pertaining to U.S. global family planning/reproductive health (FP/RH) efforts over time and identifies those currently in effect.  These laws and policies collectively serve to direct how U.S. funds are spent, to where and which organizations funds are provided, and generally shape the implementation and define the scope of U.S. global FP/RH activities. It includes U.S. laws and annual requirements enacted by Congress through appropriations bills (statutory provisions) as well as executive branch policies and guidance specific to FP/RH (policy provisions). Each category lists provisions in chronological order.

1. As noted in CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Legislation and Policy, July 2022: “No restrictions exist on funding for the medical evacuation of Peace Corps volunteers who decide to have an abortion. Under existing policy, the Peace Corps covers the cost of evacuation to a location where ‘medically adequate facilities’ for obtaining an abortion are available and where abortions are legally permissible.” ↩︎
2. In most recent years, a provision is included requiring that any Kemp-Kasten determination that is made must be accompanied by the evidence and criteria used to make the determination. ↩︎
3. USAID defines a target/quota as “a predetermined figure that a service provider or referral agent is assigned or required to affect or achieve” for the purposes of the Tiahrt Amendment. It states that “the key to interpreting ‘incentives’ is to see whether they are provided in exchange for accepting a method (in the case of a client) or linked to achievement of a predetermined target or quota (in the case of program personnel).” USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, February 2009, authored by Debbie Gueye, MSI. ↩︎
4. USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, Feb. 2009, authored by Debbie Gueye, MSI. ↩︎
5. Although such reallocation began in practice in FY 2002, it was first authorized by Congress in legislation beginning in FY 2004 with reference to FY 2002 and FY 2003 funds. ↩︎
6. Informed Choice: Effective access to information on family planning choices and to the counseling, services, and supplies needed to help individuals choose to obtain or decline services; to seek, obtain, and follow up on a referral; or simply to consider the matter further. Voluntarism: Decision to use a specific method of family planning or to use any method of family planning is based upon the exercise of free choice and is not obtained by any special inducements or any element of force, fraud, deceit, duress or other forms of coercion or misrepresentation. USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, Feb. 2009, authored by Debbie Gueye, MSI. ↩︎
7. This policy was first instituted via presidential memorandum in 1984 by President Reagan. In 1993, it was rescinded by President Clinton, although it was briefly applied legislatively in 1999 (see “Status” column). In 2001, it was reinstated by President Bush, who expanded its applicability in 2003 to include family planning funds at the State Department (see “Applies to” column) with some exemptions. In 2009, it was rescinded by President Obama. In 2017, it was reinstated by President Trump, who expanded its applicability to include the vast majority of global health assistance furnished by all departments and agencies. In 2021, it was rescinded by President Biden.. ↩︎
8. Note that, with one exception, has been applied via Executive action. The exception was in FY 2000, when President Clinton agreed to a one-year legislative codification with a partial waiver of restrictions as part of a broader arrangement to pay the U.S. debt to the United Nations. See P.L. 106-113, Sec. 599D, and PAI, Global Gag Rule Timeline, July 12, 2011. ↩︎
9. For example, one provision related to abortion included in the Standard Provisions is: “M16. VOLUNTARY POPULATION PLANNING ACTIVITIES – MANDATORY REQUIREMENTS (MAY 2006) … b. Prohibition on Abortion-Related Activities: (1)           No funds made available under this award will be used to finance, support, or be attributed to the following activities: (i) procurement or distribution of equipment intended to be used for the purpose of inducing abortions as a method of family planning; (ii) special fees or incentives to any person to coerce or motivate them to have abortions; (iii) payments to persons to perform abortions or to solicit persons to undergo abortions; (iv) information, education, training, or communication programs that seek to promote abortion as a method of family planning; and (v) lobbying for or against abortion. The term “motivate,” as it relates to family planning assistance, must not be construed to prohibit the provision, consistent with local law, of information or counseling about all pregnancy options. (2)           No funds made available under this award will be used to pay for any biomedical research which relates, in whole or in part, to methods of, or the performance of, abortions or involuntary sterilizations as a means of family planning. Epidemiologic or descriptive research to assess the incidence, extent, or consequences of abortions is not precluded.”   ↩︎