Introduction

As of 2022, there were 45.5 million immigrants residing in the U.S., including 21.2 noncitizen immigrants and 24.2 million naturalized citizens, who together account for about 15% of the total population.¹  While there has been increasing focus among some policymakers on the health care expenses incurred by immigrants, research suggests that they not only have lower health care costs than U.S.-born people but also help subsidize health care for U.S.-born people by paying more into the system through health insurance premiums and taxes than they utilize. This data note provides further insight into health care expenditures for immigrants by analyzing their average per capita health care expenditures and comparing them to expenditures for U.S.-born people overall and by health care services and payment sources using data from the 2021 Medical Expenditures Panel Survey.

This analysis finds that, on average, annual per capita health care expenditures for immigrants, including naturalized citizens and noncitizens, are about two-thirds of those for U.S.-born citizens overall ($4,875 vs. $7,277). This reflects lower spending for most types of health care, including office-based visits, prescription drugs, inpatient care, outpatient care, and dental care. Among average per capita expenditures, the relative amount paid by most payment sources is lower for immigrants compared to U.S.-born people, including private coverage, Medicare, and out-of-pocket spending. There is no significant difference in average emergency room and Medicaid expenditures between U.S.-born citizens and immigrants.

These patterns suggest that immigrants use less health care than U.S.-born people and often rely on the emergency room when they do seek care. 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 lower rates of coverage due to more limited access to private coverage and Medicaid eligibility restrictions for immigrants. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or the Children’s Health Insurance Program (CHIP), and many must wait five years after obtaining qualified status before they may enroll. Undocumented immigrants are not eligible to enroll. Immigrants also face language access challenges and confusion and fears. Increasing coverage and reducing other barriers to care for immigrants could increase the use of preventive and primary care, which could prevent the worsening of conditions and reliance on emergency room care.

Findings

In 2021, annual average overall per capita health care expenditures for immigrants were $4,875 compared to $7,277 for U.S.-born citizens. Annual average per capita spending for immigrants was lower than for U.S.-born citizens on office-based visits ($1,325 vs. $2,126), prescription drugs ($1,159 vs. $1,655) inpatient care ($864 vs. $1,284), outpatient care ($581 vs. $1,001), and dental care ($280 vs. $402) (Figure 1). Average per capita spending on emergency room care was not statistically significantly different between immigrants ($169) and U.S.-born citizens ($200).

Among average annual total per capita expenditures, the relative amount paid for by private coverage ($1,925 vs. $3,075), Medicare ($1,161 vs. $1,999), and out-of-pocket spending ($705 vs. $950) was lower for immigrants compared to U.S.-born people (Figure 2). There was no statistically significant difference in the average amount paid by Medicaid for immigrants ($854) and U.S.-born people ($830). Medicaid eligibility is limited for immigrants. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many must wait five years after obtaining qualified status before they may enroll. For children and pregnant people, states can eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. States can also extend pregnancy-related coverage to immigrants regardless of status through the CHIP From-Conception-to-End-of-Pregnancy option. Undocumented immigrants are not eligible to enroll in Medicaid. Medicaid payments for emergency services may be made for individuals who are otherwise eligible except for immigration status to help cover the costs incurred for providing this care. Given these limits, it is likely that a greater share of Medicaid spending for immigrants goes toward pregnancy-related care and emergency care, which tend to be costly. In contrast, U.S.-born enrollees include a high share of children, who typically utilize lower-cost preventive and primary care, resulting in lower spending.

1. KFF analysis of 2022 American Community Survey 1-year Public Use Microdata Sample ↩︎

This fact sheet does not reflect recent changes that have been implemented by the Trump administration, including a foreign aid review and restructuring. For more information, see KFF’s Overview of President Trump’s Executive Actions on Global Health, and also see the KFF fact sheet on the Trump administration’s foreign aid review and the status of U.S. support for Gavi.

Key Facts

• Gavi, the Vaccine Alliance (Gavi) is an independent public-private partnership and multilateral funding mechanism that aims to expand global access to and use of vaccines, particularly among vulnerable children.
• Since its launch in 2000, Gavi has provided approximately $23 billion to support immunization efforts in low- and middle-income countries, not including funding for COVAX.
• The U.S. government (U.S.) has supported Gavi since its creation through direct financial contributions, participation in Gavi’s governance, and technical assistance.
• The U.S. is the third largest contributor to Gavi and its second largest government contributor, providing 12% overall and 15% of government funding (not including COVAX). U.S. annual contributions have grown over time, reaching $300 million in FY 2024. Additionally, the U.S. recently pledged at least $1.58 billion to Gavi over the next five years for its next replenishment period.
• Additionally, the U.S. was the largest donor to COVAX, providing $4 billion in emergency funding in FY 2021 to this multilateral effort to equitably procure and distribute COVID-19 vaccines globally. Co-led and administered by Gavi, COVAX came to an end in 2023, with COVID-19 vaccines and funding now integrated into Gavi’s regular programming.
• Despite past progress in expanding access to childhood vaccinations, the COVID-19 pandemic had a detrimental impact on childhood immunization efforts in many countries, presenting new challenges for Gavi and partners going forward.
• Gavi is now launching its next replenishment effort to raise resources for the 2026-2030 period, with a pledging conference expected later this year, as well as an update to its five-year strategy.

Gavi Overview

Created in 1999 and formally launched in January 2000, Gavi, the Vaccine Alliance (Gavi) is an independent public-private partnership and multilateral funding mechanism that “aims to save lives and protect people’s health by increasing coverage and equitable and sustainable use of vaccines.” Gavi’s main activities include supporting low- and middle-income countries’ access to new and underused vaccines for vulnerable children through financial support, technical expertise, and market-shaping efforts, such as negotiating with manufacturers, to help lower the cost of procuring vaccines. Gavi operates in five-year funding cycles, with a revised strategy and goals for each cycle. Each five-year strategy is accompanied by a vaccine investment strategy, which determines which vaccines will be made available to countries.

Gavi’s current five-year strategy, for the 2021-2025 period, which is its fifth strategy, includes four core goals:

1.  introduce and scale-up vaccines,

2.  strengthen health systems to increase equity in immunization,

3.  improve sustainability of immunization programs, and

4.  ensure healthy markets for vaccines and related products.

The current strategy emphasizes reducing the number of ‘zero-dose’ children with the goal of reaching no zero-dose children by 2030; prioritizing programmatic and financial sustainability of country immunization programs; supporting countries that have phased out of Gavi support or have never been eligible for Gavi support; and providing more tailored approaches for Gavi countries to reach under-vaccinated populations, such as those living in remote or conflict settings, by encouraging countries to adopt strategies that reduce potential barriers to vaccination. Gavi is currently in the process of developing its sixth strategy.

In addition to Gavi’s role in routine childhood immunizations, Gavi was one of the organizations leading COVAX, a multilateral effort that supported the equitable development, procurement, and delivery of COVID-19 vaccines globally that began in 2020 and ended in 2023. Gavi’s role in COVAX was to facilitate the procurement and delivery of COVID-19 vaccines, with particular emphasis on low- and middle-income countries. Provision of COVID-19 vaccines and funding support to countries has now been integrated into Gavi’s regular programming; however, COVID-19 vaccine support will be discontinued after 2025.

Organization

Gavi’s Secretariat, with its main headquarters in Geneva and an office in Washington, D.C., carries out the day-to-day operations of the partnership. Gavi does not have program offices or staff based in recipient countries but rather relies on country health ministries and World Health Organization (WHO) regional offices to implement programs. Gavi is led by a Chief Executive Officer (CEO), currently Sania Nishtar.

The 28-member Gavi Board sets Gavi’s funding policies and strategic direction, and monitors program implementation. It includes 18 “representative” seats, nine seats for independent individuals, and one ex-officio non-voting seat for Gavi’s CEO. The 18 representative seats, as specified in Gavi’s statute, are as follows: donor country governments (5), implementing country governments (5), the WHO, the United Nations Children’s Fund (UNICEF), the World Bank, and the Bill & Melinda Gates Foundation, and one seat each for civil society groups, the vaccine industry in industrialized countries, the vaccine industry in developing countries, and technical health/research institutes. Additionally, several Board committees guide and advise the Board and the CEO on Gavi activities under their purview. The U.S. government is currently represented on Gavi’s Board as the Board member for the donor country government constituency and is a member of the Audit and Finance Committee, Programme and Policy Committee, and the Market-Sensitive Decisions Committee.

Funding

Since its 2000 launch, Gavi has received approximately $30 billion in financing, not including funding for COVAX (see Table 1).¹  Approximately four-fifths (80%) of Gavi’s funding came from contributions provided by donor governments and private organizations and individuals. The top three government donors were the United Kingdom, the U.S. and Norway, while the largest private donor was the Gates Foundation.

Donors support Gavi through direct contributions as well as funding commitments to innovative financing mechanisms, the proceeds of which help support Gavi’s overall financing. These innovative financing mechanisms include the International Finance Facility-Immunisation (IFFIm) and the Pneumococcal Conjugate Vaccine (PCV) Advance Market Commitment (AMC). The IFFIm was created in 2006 and uses donor funding commitments to back the issuance of special bonds in capital markets, essentially providing “up-front” financing to Gavi. The PCV AMC began in 2010, and though it ended in 2020, it supported accelerated access to pneumococcal vaccines through up-front funding commitments from donors and continues to do so through contracts with manufacturers that extend until 2029. The U.S. does not provide support to either of these mechanisms.² 

In addition to financing Gavi’s regular activities, donors pledged additional resources to support the Gavi COVAX Advance Market Commitment (COVAX AMC), a financial mechanism within COVAX that supported low- and middle-income countries through procurement and distribution of COVID-19 vaccines; through 2023, Gavi received $12.3 billion from donor governments, private philanthropy, and innovative financing mechanisms for the COVAX AMC for vaccine procurement, delivery, and logistics.³ 

Country Eligibility and Support

Eligibility

Only low- and middle-income countries with a Gross National Income (GNI) per capita below or equal to $1,730 on average over the last three years are eligible for Gavi support. In 2023, 54 countries were eligible for Gavi support; these included 23 of the 25 U.S. priority countries for maternal and child health assistance.

Recipient countries’ governments are expected to share responsibility for funding their national immunization efforts through Gavi’s co-financing requirements (introduced in 2008), determined according to country income level and transition status. As countries develop economically, they are expected to contribute a greater share of the funding required for immunization programs. Countries below the threshold (average of $1,730 GNI per capita over the past three years) and classified as low-income by the World Bank are initial self-financing countries, while countries below the threshold and classified as lower-middle income by the World Bank are in preparatory transition. Initial self-financing countries are responsible for co-financing the equivalent of $0.20 per dose each year. Countries in preparatory transition gradually increase their co-financing contribution each year.⁴  When a country’s income rises above the GNI per capita threshold, it moves into an eight-year “accelerated transition” period of increasing domestic financing share, after which the country is expected to fully fund its own immunization programs.⁵  As of 2023, 19 countries have transitioned out of Gavi financial support.

Additionally, as part of its 2021-2025 strategy, the Gavi Board approved limited support for countries that have transitioned out of Gavi eligibility and for middle-income countries (MICs) that have never been eligible for Gavi support.⁶  Recognizing that many formerly and never Gavi-eligible countries experience low coverage rates and have yet to make key vaccine introductions, an initial investment of $281 million was approved to provide limited support for 19 former and 26 never Gavi-eligible countries for political advocacy related to immunization, technical assistance, targeted assistance to reach under-vaccinated communities, and financial support for one-off costs and vaccine introductions.

Country Support

Gavi provides grant financing to country programs in the following five areas:

• Vaccine support (including for vaccine introduction, targeted campaigns, and routine campaigns),
• Health systems strengthening support (including to improve country data systems, supply chains, and community engagement, among other priority areas),
• Cold Chain Equipment Optimization Platform (CCEOP) support (for purchasing and deploying modern cold chain technology),
• Equity Accelerator Fund (EAF) support (for reaching zero-dose children and missed communities), and
• Targeted country assistance (support for country-specific needs to improve vaccine introductions and routine campaigns, through the work of partner organizations such as WHO, UNICEF, U.S. Centers for Disease Control and Prevention, and the World Bank).

Country allocations include funding ceilings, representing the maximum available funding each country can apply for during the 2021-2025 period, for all areas of support except vaccines. These ceilings are formulated based on a country’s number of zero-dose children, under-immunized children, birth cohort, and GNI per capita. For vaccines, all countries are required to pay a share of the cost of their Gavi-supported vaccines.

Additionally, Gavi has provided country support through emergency response funding, including: support for Ebola vaccination,⁷  allowing for up to $200 million in reprogrammed Gavi support for the COVID-19 response in Gavi-eligible countries, and other support for the COVID-19 response including the creation of COVAX (which helped expand access to COVID-19 vaccines in lower-income countries) and the COVID-19 Vaccine Delivery Partnership (CoVDP, which aimed to improve COVID-19 vaccine coverage in certain COVAX countries, with a particular emphasis on countries that were below 10% coverage in January 2022).⁸  In 2022, Gavi supported 40 outbreak response vaccination campaigns.

Since its launch in 2000, Gavi has provided approximately $23 billion to support country immunization programs (not including funding for COVAX).⁹  Over the past three years, 2020-2023, more than $7.3 billion has been disbursed, most of which has been for vaccine support (60%), followed by health systems strengthening (13%) (see Table 2).

Results

Gavi reports it has helped to immunize more than 1 billion children in supported countries, including more than 68 million in 2022 alone, and supported 40 different vaccine introductions and preventive campaigns and 40 outbreak response campaigns in 2022. Additionally, Gavi support has helped avert more than 17.3 million deaths and contributed to more than $220 million in economic benefits, since its launch in 2000. Additionally, according to Gavi, its support has led to improved child health and immunization indicators across its supported countries. For example, the average vaccine coverage across multiple key Gavi-supported vaccines –  including the human papillomavirus (HPV) vaccine, inactivated polio vaccine, and pentavalent vaccine (the vaccine providing protection against diphtheria, tetanus, pertussis, hepatitis B, and Hib),¹⁰  among others –  was 56% in Gavi-supported countries in 2022, up from 48% in 2019 and higher than the global average of 53%.¹¹  Lastly, Gavi’s work has contributed to vaccine market-shaping; for example, Gavi reports that its influence has helped lower the cost of the HPV vaccine from a price per dose of $4.50 in 2015 to $2.90 in 2022.

U.S. Engagement with Gavi

The U.S. government has supported Gavi since its creation. President Clinton made the initial U.S. pledge to the newly formed partnership in 2000, and the U.S. provided its first contribution in 2001. Currently, the U.S. supports Gavi through financial contributions, participation in Gavi’s governance, and by providing technical assistance. It also supports other global immunization that complement Gavi’s activities.

Financial Support

The U.S. has supported Gavi through direct contributions every year since 2001. Over the last 10 years, U.S. contributions grew from $175 million in FY 2014 to $300 million in FY 2024, which is the highest amount appropriated to Gavi thus far (see figure). Additionally, the U.S. recently pledged at least $1.58 billion to Gavi over the next five years as a sign of support for Gavi’s upcoming replenishment. Congress provides funding for U.S. contributions to Gavi through the Global Health Programs account at the U.S. Agency for International Development (USAID), specifically within the maternal and child health budget line. See the KFF budget tracker and the KFF fact sheet on the U.S. Global Health Budget: Maternal & Child Health (MCH) for details on historical appropriations for Gavi.

Additionally, in response to the COVID-19 pandemic, the U.S. provided $4 billion in FY 2021 emergency funding to Gavi COVID-19 vaccine procurement and delivery support under COVAX, making the U.S. the largest donor to COVAX (33% of $12.3 billion received overall).¹²  In addition to its financial support for COVAX, the U.S. donated the largest number of COVID-19 vaccines to other countries.

Governance Activities

A U.S. government representative (from USAID) is currently a Board member of the donor government constituency on the Gavi Board. The U.S. government is also represented on the Gavi Board’s Audit and Finance Committee, Programme and Policy Committee, and Market Sensitive Decisions Committee.

Technical Support

The U.S. also provides Gavi with technical support and expertise in the design, implementation, and evaluation of its programs in the field through partnerships with several U.S. agencies. For example, Gavi’s accelerated vaccine introduction programs have been conducted with technical support from the Centers for Disease Control and Prevention (CDC) and USAID, along with other partners.

Other U.S. Immunization Activities

Multilateral support of Gavi is one component of a broader set of global immunization activities of the U.S. government. The U.S. also provides bilateral (country-to-country) support for immunization through USAID, CDC, and other agencies, which focuses on strengthening routine immunization systems to deliver vaccines. U.S. multilateral and bilateral vaccine support are intended to be complementary. Indeed, many of the countries in which the U.S. carries out bilateral global immunization activities (provided as part of USAID’s maternal and child health efforts)  also receive support from Gavi.¹³  See the KFF fact sheets on U.S. global MCH efforts and U.S. global polio efforts.

1. This amount includes proceeds for 2000-2023 and pledges for 2024-2025. ↩︎
2. For further information about restrictions on U.S. support for these innovative financing mechanisms, see KFF, Innovative Financing Mechanisms for Global Health: Overview and Considerations for U.S. Government Participation, Sept. 2011. ↩︎
3. KFF analysis of Gavi cash receipts data. Gavi, “Cash Receipts 31 December 2023,” https://www.gavi.org/news-resources/document-library/cash-receipts. ↩︎
4. Countries in the first year of the preparatory transition phase co-finance the equivalent of $0.20 per dose, the same as initial self-financing countries. For each subsequent year, countries in preparatory transition co-finance a 15% increase of the total fraction paid in the prior year. The preparatory transition phase does have a set duration amount. Gavi, “Gavi Application Process Guidelines,” Nov. 2022, https://www.gavi.org/sites/default/files/support/ApplicationProcess_Guidelines.pdf. ↩︎
5. Countries in the first year of the accelerated transition phase co-finance the equivalent of the prior year’s total fraction plus 15%, the same as countries in preparatory transition. For each year after, the amount per dose increases linearly until the country is fully financing each vaccine after the eighth year and end of Gavi support. Gavi, “Gavi Application Process Guidelines,” Nov. 2022, https://www.gavi.org/sites/default/files/support/ApplicationProcess_Guidelines.pdf. In December 2022, the Gavi Board decided to shift the accelerated transition phase from a five-year to an eight-year timeframe. Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility. ↩︎
6. This would include countries with GNI per capita below $4,000, as well as all other IDA-eligible countries. Gavi, “Gavi’s approach to engagement with former and never-eligible Middle Income Countries (MICs),” Board presentation, Dec. 2020, https://www.gavi.org/sites/default/files/board/minutes/2020/15-dec/07%20-%20MICs%20-%20Presentation.pdf. ↩︎
7. Gavi, “500,000 doses of Ebola vaccine to be made available to countries for outbreak response,” webpage, https://www.gavi.org/news/media-room/500000-doses-ebola-vaccine-be-made-available-countries-outbreak-response. ↩︎
8. CoVDP phased out its operations in June 2023 as the partnership was not set up to be a permanent structure. WHO, “COVID-19 Vaccine Delivery Partnership,” webpage, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/covid-19-vaccine-delivery-partnership; Devex, “Exclusive: A COVID-19 initiative for vaccine delivery is winding down,” 11 January 2023, https://www.devex.com/news/exclusive-a-covid-19-initiative-for-vaccine-delivery-is-winding-down-104724. ↩︎
9. KFF analysis of data provided by Gavi on disbursements by program area and year. KFF personal communications with Gavi, Feb. 14, 2024, and Feb.10, 2023. ↩︎
10. The pentavalent vaccine is the vaccine providing protection against diphtheria, tetanus, pertussis, hepatitis B, and Hib. ↩︎
11. Breadth of protection is a measure of the average vaccine coverage across the following key Gavi-supported vaccines: last dose of human papillomavirus (HPV) vaccine, second dose of inactivated polio vaccine, third dose of pentavalent vaccine, third dose of pneumococcal conjugate vaccine, first dose of rubella-containing vaccine, last dose of the RotavirusC vaccine, second dose of measles-containing vaccine, yellow fever, meningococcal A, and Japanese encephalitis. Gavi, “Annual Progress Report 2022,” https://www.gavi.org/sites/default/files/programmes-impact/our-impact/apr/Gavi-Progress-Report-2022.pdf. ↩︎
12. The U.S. announced it would donate 500 million Pfizer doses to COVAX at the G7 Summit in June 2021. However, a portion of these doses were purchased using funds appropriated to Gavi ($2 billion for 300 million Pfizer doses), while the remaining 200 million doses were purchased using $1.5 billion in other emergency funds from the American Rescue Plan Act. To avoid double-counting, Gavi counts the U.S. funding that was contributed to Gavi under its COVAX funding contributions, with only 200 million of the doses – those purchased directly by the U.S. – counted as COVAX vaccine dose donations. KFF personal communication with Gavi, Nov. 12, 2021; White House, “FACT SHEET: President Biden Announces Historic Vaccine Donation: Half a Billion Pfizer Vaccines to the World’s Lowest-Income Nations,” June 10, 2021; Gavi, “COVAX AMC Donors Table,” Apr. 7, 2022, https://www.gavi.org/sites/default/files/covid/covax/COVAX-AMC-Donors-Table.pdf; Gavi, “Cash Receipts 30 June 20232,” https://www.gavi.org/news-resources/document-library/cash-receipts. https://www.usaid.gov/sites/default/files/documents/USAID_COVID_Response_Fact_Sheet_Oct_2021_FINAL.pdf. ↩︎
13. These included 23 of the 25 U.S. priority countries for maternal and child health assistance. KFF analysis of Gavi recipient countries and USAID maternal and child health priority countries. Gavi, “Eligibility,” webpage, https://www.gavi.org/types-support/sustainability/eligibility; USAID, “Priority Countries,” webpage, https://www.usaid.gov/global-health/health-areas/maternal-and-child-health/priority-countries. ↩︎

Hispanic Americans account for half the growth of the voting-age population in the U.S. since the 2020 presidential election, and their diversity of opinion and experiences is as great as their numbers. Former President Trump made gains with Hispanic voters between the last two presidential elections, though an analysis shows they voted for President Biden by wide margins in key states in 2020. Across racial and ethnic groups, women voters overwhelmingly cite inflation as the most important issue determining their vote and are similarly dissatisfied with their options for president. However, women of color, including both Hispanic and Black women, are less motivated to vote and less likely to say they plan to vote in this election. Hispanic women in particular are an important segment of American voters, as they have historically turned out at higher rates than Hispanic men and may be more motivated to vote in this election by the inclusion of abortion and other reproductive health measures on state-level ballots. In a close election, the turnout of Hispanic women voters may tip the scale toward either candidate.

This polling insight from the KFF Survey of Women Voters is based on analysis of Hispanic women voters nationally and in Arizona, a key battleground state for the upcoming presidential election where it is projected that one in four voters will be Hispanic¹ . This analysis finds the potential state ballot measure in Arizona which would enshrine abortion rights may motivate younger Hispanic women in particular to cast their vote.

The KFF Survey of Women Voters Dashboard includes more analyses from the survey, as well as the topline and methodology.

#1: Inflation Is the Most Important Election Issue for Hispanic Women Voters; Most Worry About Affording Basic Expenses

Economic issues are top of mind for Hispanic women voters across the country leading into the presidential election, as majorities say they worry “a lot” about affording basic expenses for them and their family, including food and groceries (64%), rent or mortgage (63%), the cost of health care (60%), monthly utilities (56%), and childcare (54% among those with children under age 18). Similar shares of Black women voters say they worry “a lot” about most of these household expenses, while White women voters are less likely than both Black and Hispanic women voters to express worry about affording the items asked about in this survey.

Americans overall have been affected by growing inflation rates after the economy struggled to recover after the COVID-19 pandemic, peaking at 9.1% in June 2022² . Over half (56%) of Hispanic women voters say “inflation, including the rising cost of household expenses” is the most important issue determining their vote in the upcoming election, and the Democratic Party has an advantage over the Republican Party when it comes to addressing the cost of household expenses for this group (35% vs. 22%). However, many still say neither party does a better job (43%).

The KFF Survey of Women Voters Dashboard displays top issues determining the vote of Hispanic women voters and other key groups of women voters.

#2: Hispanic Women Voters Are Frustrated, Dissatisfied With Options for President; Younger Voters Are Particularly Disaffected

About six in ten Hispanic women voters nationally say they are “anxious” (60%) or “frustrated” (57%) about the upcoming presidential election, while half (54%) say they are “hopeful,” and a much smaller share are “enthusiastic” (35%). Negative feelings surrounding the election may be related to dissatisfaction with the candidates themselves. The poll, fielded before the first presidential debate between President Biden and former President Trump, found over half (55%) of Hispanic women voters say they are dissatisfied with their options for president, including a quarter (27%) who say they are “not at all” satisfied.

Younger Hispanic women voters are particularly disaffected this election cycle. One-third (32%) of those ages 18 to 44 say they are less motivated to vote compared to previous presidential elections (19% of Hispanic women voters ages 45 and older respond similarly), and a quarter (26%) say they would not vote if the election were held today. Younger Hispanic women are also more likely to identify as independent compared to those 45 and older (40% vs. 25%). This patten is consistent across racial and ethnic groups nationally, with younger women more likely than their older counterparts to identify as independent.

In addition, the KFF Survey of Women Voters, which was fielded in late May to early June, finds lack of motivation to vote among younger Hispanic women may be related to their mixed views on the candidates’ records. Half (52%) of Hispanic women voters ages 18 to 44 say they were better off financially during Trump’s presidency, compared to one in ten who say they are better off now under President Biden and about four in ten (37%) who say there is no difference. Financial security appears top of mind for this voting bloc, among whom six in ten cite inflation as the top issue determining their vote (62%).

Though Trump may have a comparative advantage on voters’ perceptions of their financial situations during his presidency, Biden does better among younger Hispanic women voters on reproductive health issues. This group is over twice as likely to say they trust Biden over Trump to do a better job deciding policy related to abortion access (40% vs. 19%) and birth control access (45% vs. 18%) in the U.S. Though once again, four in ten say they trust neither candidate to do a better job in each of these areas (41% and 37%, respectively).

#3: In Arizona, a Key Battleground State, the Arizona Right to Abortion Initiative May Drive Turnout Among Younger Hispanic Women Who Support Abortion Rights

Analysis suggests that turnout of young Hispanic voters in Arizona was a key part of President Biden’s narrow victory in the state in 2020. The candidate who wins the 11 electoral college votes in this swing state in 2024 could tip the scale for who wins the presidency, especially if this crucial voting bloc turns out once again.

Fielded in late May to early June, the KFF Survey of Women Voters finds about one third (32%) of younger Hispanic women voters ages 18 to 44 in Arizona say there is a 50-50 chance or less of voting in the upcoming November election. Just 7% of older Hispanic women voters, ages 45 and older, say the same. These younger voters are also more likely to not affiliate with either political party (40% vs. 14% who identify as independents). These patterns among younger Hispanic women voters in Arizona are also found among this group nationally.

If the presidential candidates are not motivating younger Hispanic women in Arizona to vote, a citizen-initiated amendment to the state constitution enshrining abortion rights, which will likely appear on the ballot, may encourage this group to turn out. A large majority (82%) of Hispanic women voters ages 18 to 44 say they support the Arizona Right to Abortion Initiative, which would establish a fundamental right to abortion until fetal viability, typically between 23 and 25 weeks of pregnancy. Notably, two-thirds (67%) of younger Hispanic women voters say they would be more motivated to vote if it makes it on the state ballot. Smaller shares of Hispanic women ages 45 and older say they support the measure (46%) and would be more motivated to vote if it is on the ballot (45%).

#4: President Biden Has the Advantage Among Hispanic Women in Arizona on Abortion, Though Many Still Trust “Neither Candidate”

During the first presidential debate in June (held after the field period for the survey), both President Biden and former President Trump reaffirmed their stances on abortion. Biden declared his commitment to restoring Roe v. Wade, which would secure a federal right to abortion until fetal viability, akin to the Arizona Right to Abortion Initiative which young Hispanic women in the state overwhelmingly support. In contrast, Trump stated the legal status of abortion should be left to the states to decide, a policy stance that 77% of younger Hispanic women voters from Arizona oppose. A majority (59%) of Hispanic women voters in Arizona, regardless of age, say this year’s election for president will have a “major impact” on access to abortion and reproductive health care in their state. However, while younger Hispanic women voters are twice as likely to say they trust Biden over Trump when it comes to deciding policy related to abortion and birth control access in the U.S., three in ten or more still say they trust “neither” candidate.

Hispanic women who cast their ballot in the upcoming 2024 presidential election will be deciding between two candidates whose incoming tenure will address policy related to inflation, threats to democracy, immigration, and abortion – all top issues determining the vote of this growing voting bloc. In Arizona, a state with a growing Hispanic electorate that is majority younger and female, it is unclear whether turnout of young Hispanic women who may show up to vote for the Arizona abortion rights measure will translate to an advantage for either candidate. With substantial shares declaring trust in neither candidate to address reproductive health issues, alongside disaffection towards the election overall, the presidential nominees will each need to convince this bloc of largely disaffected voters that his presidency will best address their needs and top issues.

1. Hispanic women voters include any women voters who identify as Latino or Hispanic, regardless of racial identity. ↩︎
2. The most recent Consumer Price Index, measuring the rate of inflation between May 2023 and May 2024 is 3.3%. ↩︎

A new KFF analysis finds that firearms are involved in the majority of all homicides and suicides in the U.S., playing a role in 79% of homicides and 55% of suicide deaths in 2022, the most recent data available.The analysis, based on data from the federal Centers for Disease Control and Prevention, also shows that firearm deaths increased sharply over the decade, from 33,563 deaths in 2012 to 48,204 deaths in 2022. Looked at another way, the firearm-related death toll rose from 92 deaths per day in 2012 to 132 deaths per day in 2022, a period marked by increasing public concern about gun violence in the U.S.  

Firearms surpassed motor vehicle accidents to become the leading cause of death for young adults (ages 18 to 25) in 2015, and the leading cause of death among children and adolescents (1-17) in 2020. Over half of adults report a gun-related incident personally or among family, according to KFF polling, and one-fifth report the death of a family member due to a firearm.The new analysis finds overall gun deaths rates rose by 35% from 2012 to 2022, with a sharper rise in firearm homicide rates compared to firearm suicide rates (69% vs. 31%, respectively). While firearm-related homicides have spiked more in recent years, suicides still accounted for a majority (56%) of all firearm deaths in 2022. Cumulatively this translates to nearly 100,000 more firearm suicides compared to homicides over the 2012 to 2022 period (258,062 vs. 164,139).Other key takeaways include:

• Males were six times more likely to die from firearms than females in 2022.
• In young adults, firearm suicides make up 40% of all firearm deaths and that share steadily climbs with age, up to 91% among older adults (65+). The pattern for homicides is the opposite, with a higher rate in young adults that declines with age. Young adults had the highest overall firearm death rate compared to all other age groups in 2022.
• Firearm deaths have sharply increased among Black and American Indian or Alaska Native (AIAN) people, while remaining relatively steady among White people. Further, while about 80% of firearm deaths among White people are due to suicides, about 80% of firearm deaths among Black people are due to homicides in 2022.
• Firearm death rates vary widely across states, with a nearly tenfold difference in rates between states with the lowest and highest rate (from  3.1 deaths per 100,000 in Rhode Island to 29.6 in Mississippi in 2022).  
• The type of firearm death (suicide, homicide, or other) also varies by state, with firearm suicides making up over 80% of all firearm deaths in Utah and New Hampshire, while homicides account for the largest share of deaths in District of Columbia and Maryland.   

The full analysis, as well as other data and analyses related to gun violence in the U.S., is available at kff.org.

Firearm deaths increased sharply over the past decade, rising from 92 deaths per day to 132 deaths per day from 2012 to 2022. During that time, firearms surpassed motor vehicle accidents to become the leading cause of death for young adults in 2015, and the leading cause of death among children and adolescents in 2020. Over half of adults report a gun-related incident personally or among family, according to KFF polling, and one-fifth report death of a family member due to a firearm. On the second anniversary of the Bipartisan Safer Communities Act, the Surgeon General issued an Advisory, declaring gun violence a public health crisis. Headed into the presidential election, debate about firearms is likely to continue to be an area of stark contrast between candidates.

This analysis uses the most comprehensive and recent firearm death data available from CDC WONDER to examine firearm deaths from a decade of data (2012-2022), including who is affected, trends, and state-level differences. This analysis of firearm deaths includes suicides, homicides, and other firearm-related deaths (including accidents, legal intervention, and undetermined). Firearm suicide and homicides are often combined under the term, “firearm violence” or “gun violence”.

Key takeaways include the following:

• The total firearm death rate increased by 35% from 2012 to 2022. Firearm homicides increased more sharply during the pandemic, but firearm suicides continue to account for over half of firearm deaths. Firearms account for more than half of all suicide and homicide deaths.
• Firearm deaths are the leading cause of death among young adults (ages 18-25) and occur at a higher rate in this age group than in any other. Firearm deaths in young adults are predominantly due to homicides, while suicides account for the largest share of firearm deaths in older adults.
• Firearm deaths have sharply increased among Black and American Indian or Alaska Native (AIAN) people, while remaining relatively steady among White people. Further, while about 80% of firearm deaths among White people are due to suicides, about 80% of firearm deaths among Black people are due to homicides.
• Firearm death rates vary widely across states, with nearly a tenfold difference between the lowest and highest states. Nearly all states experienced an increase in firearm deaths from 2012 to 2022. Further, distribution of type of firearm death varies widely across states – with firearm suicides being predominant in some states, and firearm homicides in others.

How have the amount and distribution of firearm deaths changed over time?

When adjusted for population growth and age, the total firearm death rate has increased by 35% from 2012 to 2022, moving from 10.5 to 14.2 deaths per 100,000 people (Figure 1). Firearm deaths began to steadily rise in 2014, before sharply accelerating during the pandemic. Although there was a small decrease in deaths from 2021 to 2022, these years still have the highest number of firearm deaths in CDC record (since 1999).

Firearm homicides sharply increased in recent years; however, suicides still account for more total firearm deaths, making up 56% of these deaths in 2022. Total firearm homicides increased by 69% from 11,622 to 19,651, and the number of firearm suicides increased by 31% from 20,666 to 27,032. Despite the larger increase in firearm homicides, firearm suicides consistently accounted for more than half of total firearm deaths from 2012 (62%) to 2022 (56%) (Figure 2). Cumulatively this translates to nearly 100,000 more firearm suicides compared to homicides over the 2012 to 2022 period (258,062 vs. 164,139).

Firearms are the leading cause of total suicides and homicides, making up 55% of all suicide deaths and 79% of all homicides in 2022 (Figure 3). Firearm suicides are the most lethal method of suicide attempt, and their recent increase has led to the highest number of total suicides on CDC record. At the same time, non-firearm suicides have decreased. With about half of suicide attempts occurring within 10 minutes of the current suicide thought, access to firearms is a suicide risk factor. Efforts to reduce firearm suicides include the development of 988 and crisis services, increasing education about the link between firearm ownership and suicide risk (lethal means counseling) and providing safety locks to at-risk firearm owners. For homicides, firearms account for 79% of total homicide deaths in 2022 (Figure 3). Focused interventions, such as hospital and community violence intervention programs, have been pointed to as potential paths to reducing firearm homicides.

What are trends in firearm deaths by demographic?

Firearm death rates vary by demographics and were consistently higher among young adults, Black people, and males compared to their respective peers from 2012 to 2022 (Figure 4). For example:

• Young adults (ages 18-25) had the highest rate of firearm deaths compared to all other age groups in 2022; however, adults ages 26-44 have experienced the fastest growth in these death rates over time (Figure 4). Between 2012 and 2022, the firearm death rate among young adults increased by 37%, from 17.7 to 24.3 deaths per 100,000, surpassing motor vehicle accidents as the leading cause of death among young adults in 2015. Adults ages 26 to 44 experienced the fastest growth in these death rates over time, with their rate rising 48% from 2012 to 2022 (13.7 vs. 20.3 per 100,000 people, respectively).
• Firearm death rates in 2022 as well as rates of increase from 2012 to 2022 were highest for Black and AIAN people. In 2022, firearm death rates for Black (33.2 per 100,000) and AIAN people (22.2 per 100,000) far exceeded the rate for White people (12.2 per 100,000) (Figure 4). Further, from 2012 to 2022, the firearm death rate increased by 75% for Black people and 90% for AIAN people, compared to 22% for White people. The firearm death rate was lowest for Asian/PI people, at 3.0 per 100,000 people in 2022.
• Males were six times more likely to die from firearms than females (24.6 vs. 4.1 per 100,000) in 2022 (Figure 4). Firearm death rates were consistently higher for males compared to females over time, although both groups experienced increases from 2012 to 2022. Men are about twice as likely to own a firearm compared to women. During the pandemic, firearm purchases by women rose, which may lead to shifts in these demographic trends of firearm deaths in coming years.

Patterns in the distributions of firearm suicide and homicide deaths vary across race and ethnicity and age (Figure 5). For example:

• Firearm deaths in young adults are predominantly due to homicides, while suicides account for the largest share of deaths among older adults. Firearm homicides peak in young adults, accounting for nearly two-thirds of all firearm deaths in this age group. The share of firearm homicides steadily decreases with age, dropping to less than 10% by age 65+. Conversely, suicides make up a smaller share of firearm deaths in young adults but increase with age, comprising 91% of all firearm deaths in the 65+ age group.
• About eighty percent of firearm deaths among White people are suicides, while 80% among Black people are homicides. Among other racial and ethnic groups, the distribution of homicide and suicide firearm deaths is more mixed. These differences may be tied to underlying structural inequities such as poverty and racism, which are linked to higher homicide rates. They may also reflect differences in firearm ownership rates, as White people are more likely to own firearms and firearm availability is closely tied to suicide risk. Although 8 in 10 firearm deaths among Black people are homicides, this share has decreased since 2012, reflecting a sharper relative growth in firearm suicides among Black people. This group has also experienced rising mental health needs and low treatment rates.
• Homicides account for a somewhat larger share of firearm deaths among females compared to males. The share of firearm homicides is higher in females (47% vs. 40%), whereas the share of firearm suicides is larger in males. Suicide risk is tied to gun ownership and men are about twice as likely to own a firearm compared to women. Further, many female firearm homicides are linked to intimate partner violence.

How do firearm deaths vary by state?

Firearm death rates vary widely across states, with nearly a tenfold difference between the lowest rate in Rhode Island (3.1 per 100,000) and the highest in Mississippi (29.6 per 100,000). In 2022, about two-thirds of states had firearm death rates above the national average of 14.2 per 100,000, with the highest rates in Mississippi, Louisiana, and New Mexico. About one-third of states, including Rhode Island, Massachusetts, and New Jersey, had rates below the national average. From 2012 to 2022, firearm death rates increased in all states – except Rhode Island and New Jersey – with rate increases ranging from 1% in Wyoming to 128% in the District of Columbia (Figure 6). Variations in firearm death rates may be due to a combination of factors, including rates of firearm ownership, and other state policies—which may include child access prevention laws. At the end of last year, the White House Office of Gun Violence Prevention was established with one of its goals being to partner with states to address gun violence. The office recommended that states create their own gun violence prevention offices. While a few states already had similar offices, Maryland recently formed its own and more states may have efforts underway.

The type of firearm death varies by state, with suicide predominant in some states, homicide in others, and some states more evenly mixed. Nationally, suicides account for 56% of all firearm deaths, homicides account for 41%, and other firearm deaths account for 3%, but these proportions differ substantially at the state level. For instance, in Utah and New Hampshire suicides account for most firearm deaths (over 80%). In contrast, in the District of Columbia and Maryland, homicides make up about 65% or more of the state’s firearm deaths. Other states, like Pennsylvania and Georgia, have a more even split. Age-adjusted rates show the magnitude of each type of firearm death by state, adjusted for age and population. For instance, Montana has the highest firearm suicide death rate (20.0 per 100,000 people), whereas D.C. has a similarly high rate, but for firearm homicides (21.0 per 100,000 people) (Figure 7). While the reasons behind these variations in distribution aren’t entirely clear, they may be linked to factors like gun ownership rates, policy, and economic factors.

Ahead of the 2024 Republican National Convention, the party has softened its language around access to abortion in a draft version of the party platform, mirroring the stance of the former president and Republican nominee, Donald Trump. Many major media outlets report that this platform change is likely a move to reduce vulnerability on the issue of abortion in the run up to the election. In fact, this will be the first time in 40 years that the Republican Party’s platform does not call for a federal ban on abortion.

While a majority of rank-and-file Republicans oppose a law guaranteeing a nationwide right to abortion, many support laws allowing access to abortion in certain situations. For example, most Republican and Republican-leaning independent women voters say they support leaving it up to the states to decide whether abortion is legal (60%) or a law establishing a nationwide ban on abortion after 15 weeks of pregnancy (57%). But large majorities of Republican women also support laws protecting access to abortion for patients who are experiencing pregnancy-related emergencies (79%) and a federal law protecting access to abortions in the case of rape or incest in all states even where abortion is banned (69%).

Republican women of reproductive age, ages 18 to 49, hold slightly less conservative views on abortion policies and a slim majority support a law guaranteeing a nationwide right to abortion (53%). Similar shares of younger Republican women voters support leaving it up to the states to decide whether abortion is legal (54%) or support a nationwide ban on abortion at 15 weeks (53%). With about half of younger Republican women voters supporting each of these three policy proposals, it is clear that there is some uncertainty among these voters on how abortion access should be addressed at the federal level. Still, most younger Republican women support access to abortion in certain cases, most notably in instances where patients are experiencing pregnancy-related emergencies.

Republican women voters’ views on abortion are not monolithic. While most (58%) Republican women voters identify as “pro-life,” many (40%) say on the issue of abortion they are more “pro-choice.” In addition, half of Republican women voters think abortion should be legal in all or most cases, the same as the share who say abortion should be illegal. Just 13%, or about one in eight, Republican women voters say abortion should be illegal in all cases.

Once again, views differ slightly by age, with similar shares of Republican women voters of reproductive age (ages 18 to 49) saying they identify as “pro-life” (49%) and “pro-choice” (51%), while two-thirds of older Republican women voters identify as “pro-life.” In addition, a majority (56%) of younger Republican women voters say abortion should be legal in at least most cases, including one in five who say abortion should be legal in all cases.

While two-thirds of Republican women voters say they trust former President Trump to do a better job deciding abortion policy in this country compared to President Biden, a quarter of Republican women say they trust neither presidential candidate to do a better job on this issue. Additionally, one in three Republican women voters (34%) say neither political party does a better job of looking out for the interests of women. In fact, 16% of Republican women of reproductive age say they think the Democratic Party does a better job of looking out for the interests of women than the Republican Party.

Once a cornerstone issue for the Republican Party – with most single-issue abortion voters being pro-life and Republican prior to the Dobbs decision – abortion is no longer a top voting issue for Republican voters since Roe v. Wade was overturned. Fewer than one in ten Republican women (7%) say abortion is the most important issue to their vote (compared to 13% of Democratic women voters), well behind issues such as inflation (47%) and immigration (26%). Abortion also ranks lower than inflation for independent women (10%) alongside immigration and threats to democracy as their most important voting issue. The dashboard shows how abortion ranks as a voting issue for the different groups of women voters including partisans, across age groups, and race and ethnicity.

While the issue may not be motivating Republican women to go to the polls (just 3% of Republican women voters say they would only vote for a candidate who agrees with them on abortion), the party’s overall stance – which had been largely seen as anti-abortion – may be disenchanting some voters.

The KFF Survey of Women Voters, conducted earlier this summer, shows many women voters, including Republican women, are not satisfied with their choices of presidential candidates. While Republican women report being slightly more motivated to vote compared to Democratic women, younger Republican women largely feel like the Republican Party doesn’t share their views on reproductive health issues and want abortion to be legal in most cases. While many early reports about the drafted changes to the Republican National Convention party platform speculate that they are written to appease the Republican nominee for President, these changes also, perhaps coincidentally, could help the party appeal to a key voting base – Republican women.

Registered Nurses (RNs) play a key role in the health care workforce and contribute to the health and well-being of millions of Americans, working in hospitals, nursing homes, physician’s offices, and home health services. The profession has been experiencing shortages, which were exacerbated by the COVID-19 pandemic and are predicted to continue over the next decade as the 65 and older population in the U.S. grows, increasing health care needs. Demand for nurses will also likely increase to meet new requirements for nurse staffing levels in nursing facilities.

Immigrant workers could help address these needs. As of 2022, there were about 500,000 immigrant nurses in the U.S., accounting for about one in six of the close to 3.2 million RNs.¹  However, immigration remains a hot-button political issue with ongoing anti-immigrant rhetoric and recent actions and proposals to limit immigration and immigrants’ role in the workforce. These actions include the federal government extending its pause on the processing of new visa applications for international nurses in June 2024. The pause has been in place since April 2023 and, at this time, the government is only processing applications submitted on or before December 2021. Legislation has been proposed to increase employment-based visas for nurses, although it has remained stalled since 2023. Visa opportunities for nurses could also potentially be expanded through administrative action, for example via H-1B visas, though they would have limitations.

These visa restrictions could exacerbate existing shortages in the nursing workforce and negatively impact the U.S. labor market and economy more broadly, particularly given the growing role of foreign-educated nurses in U.S. hospitals. KFF analysis of data from the American Hospital Association (AHA) Annual Survey shows that the overall share of hospitals reporting hiring foreign-educated RNs has nearly doubled between 2010 and 2022, and a growing share of hospitals report hiring an increasing number of foreign-educated RNs to fill vacancies over time.

Overall, 32% of hospitals accounting for nearly half (45%) of all hospital beds say they hired foreign-educated RNs in 2022, twice the share in 2010, when 16% of hospitals accounting for about a quarter (23%) of all hospital beds said they hired foreign-educated RNs (Figure 1). In addition, between 2010 and 2022, the share of hospitals saying they hired more foreign-educated nurses to help fill RN vacancies compared to the previous year rose from 2% of hospitals representing 3% of hospital beds to 14% of hospitals representing 22% of hospital beds (Figure 2).

1. KFF analysis of 2022 American Community Survey. ↩︎

The House Committee on Appropriations released its FY 2025 Labor, Health and Human Services, Education, and Related Agencies (Labor HHS) appropriations bill on June 26, 2024 and accompanying report on July 9, 2024. The Labor HHS appropriations bill includes funding for U.S. global health programs provided to the Centers for Disease Control and Prevention (CDC) and funding for global health research activities provided to the National Institutes of Health (NIH). Total global health funding at CDC and NIH through the Labor HHS bill is not yet known, as funding for some programs at NIH is determined at the agency level rather than specified by Congress in annual appropriations bills. Funding for global health programs at CDC totals $564 million, which is $129 million (-19%) below both the FY24 enacted level and President’s FY25 request ($693 million). The bill would eliminate all funding for global HIV programs at CDC; all other program areas would be flat funded compared to enacted and request levels. Also, the report includes a provision requesting an update in the FY 2026 congressional budget justification on how agencies “jointly coordinate global health research activities with specific metrics to track progress and collaboration toward agreed upon health goals.” See the table below for additional detail on global health funding. See other budget summaries and the KFF budget tracker for details on historical annual appropriations for global health programs.