The Facts About the $35 Insulin Copay Cap in Medicare

Published: Jun 12, 2024

Compare the records and policy positions of President Trump and Vice President Harris on drug costs and other health issues. 

In a recent post on his social media platform, Donald Trump claimed credit for lowering insulin copayments to $35 for “millions of Americans,” stating – inaccurately – that President Biden had “nothing to do with it.” This brief walks through the facts about actions taken under both the Trump and Biden Administrations related to capping insulin copayments for people with Medicare and explains the differences between their approaches.

What did the Trump Administration do?

In 2020, the Trump Administration established a voluntary, time-limited model under the Center for Medicare and Medicaid Innovation known as the Part D Senior Savings Model. Under this model, participating Medicare Part D prescription drug plans covered at least one of each dosage form and type of insulin product at no more than $35 per month. The model was in effect from 2021 through 2023, and less than half of all Part D plans chose to participate in each year.

What did the Biden Administration do?

In 2022, President Biden signed into law the Inflation Reduction Act, which included a provision that requires all Part D plans to charge no more than $35 per month for all covered insulin products, and also limits cost sharing for insulin covered under Part B to $35 per month. Deductibles no longer apply to insulins under Part D or Part B. These provisions took effect in 2023 (January 1 for Part D; July 1 for Part B).

What are the key differences between these approaches?

There are three key differences between these approaches (Figure 1):

This text chart is Comparing $35 Insulin Copayment Caps Under the Trump and Biden Administrations
  • Applies to all Part D plans? The Trump Administration’s model relied on voluntary Part D plan participation, while the Biden Administration copay cap applies under all Part D plans. In 2022, a total of 2,159 Part D plans participated in the Trump Administration’s model, including both stand-alone prescription drug plans and Medicare Advantage drug plans, which is 38% of all Part D plans that year. Under the Inflation Reduction Act, the $35 copay cap is available in all 6,000 Part D plans available in 2024.
  • Applies to all covered insulins in Part D? Under the Trump Administration’s model, participating plans were not required to cover all insulin products at the $35 monthly copayment amount, just one of each dosage form (vial, pen) and insulin type (rapid-acting, short-acting, intermediate-acting, and long-acting). Under the Biden Administration, the $35 copay cap in Part D extends to all insulin products that a Part D plan covers.
  • Part D and Part B? The Trump Administration’s model applied only to insulin covered under Part D. The Biden Administration copay cap applies to insulins covered under both Part D and Part B.

While Trump claimed that he extended lower insulin pricing to “millions of Americans,” CMS estimates that around 800,000 insulin users had access to $35 insulin copays under the Part D Senior Savings Model in 2022. In contrast, the $35 copay cap under President Biden’s Inflation Reduction Act provision is available to all insulin users enrolled in all Medicare Part D plans – an estimated 3.3 million in 2020, based on KFF estimates – as well as those who take insulins covered under Part B.

The Trump Administration’s $35 insulin copay model had a more limited reach than the insulin copay cap now in place under the Inflation Reduction Act that President Biden signed into law, because the model was voluntary and because Part D plans could select which of their covered insulin products they wanted to make available at the $35 monthly copay. Under the insulin copay cap that took effect under the Inflation Reduction Act, insulin users in all Part D plans pay no more than $35 per month for any insulin product covered by their Part D plan.

What the November election could mean for people who need insulin

President Biden has proposed to extend the $35 monthly cap on insulin out-of-pocket costs to people with commercial insurance. The Biden Administration and Senate Democrats included a similar provision in the Inflation Reduction Act, but that provision was stripped from the final legislation after the vast majority of Republicans voted to remove it. According to KFF analysis, more than 1 in 4 insulin users in the individual and small group markets and about 1 in 5 insulin users with large employer coverage paid, on average, more than $35 per month out-of-pocket for insulin in 2018.

The House Republican Study Committee proposed a full repeal of the Inflation Reduction Act in its FY2025 budget proposal. While it is unclear whether Trump supports repealing this law in its entirety, doing so would eliminate the $35 insulin copay cap for millions of insulin users with Medicare and leave in its place only voluntary efforts offered by the three major insulin manufacturers, which apply to many people irrespective of their health coverage.

News Release

Costly GLP-1 Drugs are Rarely Covered for Weight Loss by Marketplace Plans

For Drugs Used to Treat Diabetes, Plans Almost Always Require Prior Authorization or Other Utilization Management

Published: Jun 12, 2024

Affordable Care Act (ACA) Marketplace plans rarely cover GLP-1 drugs approved solely for obesity treatment, according to a new KFF analysis of 2024 federal plan data. Wegovy, a drug that is approved for weight loss, is covered by just 1% of Marketplace prescription drug plans, compared to 82% of Marketplace prescription drug plans for Ozempic, which contains the same active ingredient as Wegovy (semaglutide) but is approved only for diabetes.

When GLP-1 drugs are covered for diabetes treatment, almost all plans use at least one utilization management strategy to control costs, such as prior authorization or quantity limits. Of the few Marketplace plans that cover GLP-1 drugs approved for obesity, all require prior authorization.

Utilization management tools are intended to balance cost control and access but may still pose barriers for people with a medical necessity to take these drugs. While insurers receive rebates to offset some of their costs, the list prices of GLP-1 drugs are about $1,000 per month, and growing demand for these medications could put upward pressure on premiums.

This analysis examines publicly available formularies of plans available on the federally facilitated ACA Marketplaces in 2024 and does not include states that run their own Marketplaces, where coverage patterns may differ. The ACA Marketplaces represent a small share of people with private health insurance, as most people with private coverage have plans sponsored by their employers. While information on employer plan formularies is not publicly available, these plans may be more likely to cover drugs for weight loss than ACA Marketplace plans given the desire to attract workers, though they may employ similar utilization management strategies.

Insurer Strategies to Control Costs Associated with Weight Loss Drugs

Authors: Justin Lo and Cynthia Cox
Published: Jun 12, 2024

Affordable Care Act (ACA) Marketplace plans rarely cover GLP-1 drugs approved solely for obesity treatment, according to a an analysis of 2024 federal plan data. Wegovy, a drug that is approved for weight loss, is covered by just 1% of Marketplace prescription drug plans, compared to 82% of Marketplace prescription drug plans for Ozempic, which contains the same active ingredient as Wegovy (semaglutide) but is approved only for diabetes.

This analysis examines publicly available formularies of plans available on the federally facilitated ACA Marketplaces in 2024 and does not include states that run their own Marketplaces, where coverage patterns may differ. The ACA Marketplaces represent a small share of people with private health insurance, as most people with private coverage have plans sponsored by their employers.

The full chart collection and other data on health costs are 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.

Key Data on Health and Health Care by Race and Ethnicity

Published: Jun 11, 2024

Executive Summary

Introduction

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Racial and ethnic disparities in health and health care remain a persistent challenge in the United States. The COVID-19 pandemic’s uneven impact on people of color drew increased attention to inequities in health and health care, which have been documented for decades and reflect longstanding structural and systemic inequities rooted in historical and ongoing racism and discrimination. KFF’s 2023 Survey on Racism, Discrimination, and Health documents ongoing experiences with racism and discrimination, including in health care settings. While inequities in access to and use of health care contribute to disparities in health, inequities across broader social and economic factors that drive health, often referred to as social determinants of health, also play a major role. Using data to identify disparities and the factors that drive them is important for developing interventions and directing resources to address them, as well as for assessing progress toward achieving greater equity over time.

This analysis examines how people of color fare compared to White people across 64 measures of health, health care, and social determinants of health using the most recent data available from federal surveys and administrative sets as well as the 2023 KFF Survey on Racism, Discrimination, and Health, which provides unique nationally-representative measures of adults’ experiences with racism and discrimination, including in health care (see About the Data). Where possible, we present data for six groups: White, Asian, Hispanic, Black, American Indian or Alaska Native (AIAN), and Native Hawaiian or Pacific Islander (NHPI). People of Hispanic origin may be of any race, but we classify them as Hispanic for this analysis. We limit other groups to people who identify as non-Hispanic. When the same or similar measures are available in multiple datasets, we use the data that allow us to disaggregate for the largest number of racial and ethnic groups. Future analyses will reflect new federal standards that will utilize a combined race and ethnicity approach for collecting information and include a new category for people who identify as Middle Eastern or North African. Unless otherwise noted, differences described in the text are statistically significant at the p<0.05 level.

We include data for smaller population groups wherever available. Instances in which the unweighted sample size for a subgroup is less than 50 or the relative standard error is greater than 30% — which are outside of what we would typically include in analysis like this — are noted in the figures, and confidence intervals for those measures are included in the figure. Although these small sample sizes may impact the reliability, validity, and reproducibility of data, they are important to include because they point to potential underlying disparities that are hidden without disaggregated data. For some data measures throughout this brief we refer to “women” but recognize that other individuals also give birth, including some transgender men, nonbinary, and gender-nonconforming persons.

Key Takeaways

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Black, Hispanic, and AIAN people fare worse than White people across the majority of examined measures of health and health care and social determinants of health (Figure 1). Black people fare better than White people for some cancer screening and incidence measures, although they have higher rates of cancer mortality. Despite worse measures of health coverage and access and social determinants of health, Hispanic people fare better than White people for some health measures, including life expectancy, some chronic diseases, and most measures of cancer incidence and mortality. These findings may, in part, reflect variation in outcomes among subgroups of Hispanic people, with better outcomes for some groups, particularly recent immigrants to the U.S. Examples of some key findings include:

  • Nonelderly AIAN (19%) and Hispanic (18%) people were more than twice as likely as their White counterparts (7%) to be uninsured as of 2022.
  • Among adults with any mental illness, Hispanic (40%), Black (38%), and Asian (36%) adults were less likely than White adults (56%) to receive mental health services as of 2022.
  • Roughly, six in ten Hispanic (63%), AIAN (63%), and Black (58%) adults went without a flu vaccine in the 2022-2023 season, compared to less than half of White adults (49%).
  • AIAN (67.9 years) and Black (72.8 years) people had a shorter life expectancy compared to White people (77.5 years) as of 2022, and AIAN, Hispanic, and Black people experienced larger declines in life expectancy than White people between 2019 and 2022; however, all racial and ethnic groups experienced a small increase in life expectancy between 2021 and 2022.
  • Black (10.9 per 1,000) and AIAN (9.1 per 1,000) infants were at least two times as likely to die as White infants (4.5 per 1,000) as of 2022. Black and AIAN women also had the highest rates of pregnancy-related mortality.
  • AIAN (24%) and Black (21%) children were more than three times as likely to have food insecurity as White children (6%), and Hispanic children (15%) were over twice as likely to have food insecurity than White children (6%) as of 2022.
Health and Health Care among People of Color Compared to White People

Asian people in the aggregate fare the same or better compared to White people for most examined measures. However, they fare worse for some measures, including receipt of some routine care and screening services, and some social determinants of health, including home ownership, crowded housing, and experiences with racism. They also have higher shares of people who are noncitizens or who have limited English proficiency (LEP), which could contribute to barriers to accessing health coverage and care. Moreover, the aggregate data may mask underlying disparities among subgroups of the Asian population. Asian people also report experiences with discrimination in daily life, which is associated with adverse effects on mental health and well-being.

Data gaps largely prevent the ability to identify and understand health disparities for NHPI people. Data are insufficient or not disaggregated for NHPI people for a number of the examined measures. Among available data, NHPI people fare worse than White people for the majority of measures. There are no significant differences for some measures, but this largely reflects the smaller sample size for NHPI people in many datasets, which limits the power to detect statistically significant differences.

These data highlight the importance of continued efforts to address disparities in health and health care and show that it will be key for efforts to address factors both within and beyond the health care system. While these data provide insight into the status of disparities, ongoing data gaps and limitations hamper the ability to get a complete picture, particularly for smaller population groups and among subgroups of the broader racial and ethnic categories. As the share of people who identify as multiracial grows, it will be important to develop improved methods for understanding their experiences. How data are collected and reported by race and ethnicity is important for understanding disparities and efforts to address them. Recent changes to federal standards for collecting and reporting racial and ethnic data are intended to better represent the diversity of the population and will likely support greater disaggregation of data to identify and address disparities.

Racial Diversity Within the U.S. Today

TOTAL POPULATION BY RACE AND ETHNICITY

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About four in ten people (42%) in the United States identify as people of color (Figure 2). This group includes 19% who are Hispanic, 12% who are Black, 6% who are Asian, 1% who are AIAN, less than 1% who are NHPI, and 5% who identify as another racial category, including individuals who identify as more than one race. The remaining 58% of the population are White. The share of the population who identify as people of color has been growing over time, with the largest growth occurring among those who identify as Hispanic or Asian. The racial diversity of the population is expected to continue to increase, with people of color projected to account for over half of the population by 2050. Recent changes to how data on race and ethnicity are collected and reported may also influence measures of the diversity of the population.

Total United States Population by Race and Ethnicity, 2022

RACIAL DIVERSITY BY STATE

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Certain areas of the country—particularly in the South, Southwest, and parts of the West—are more racially diverse than others (Figure 3). Overall, the share of the population who are people of color ranges from 10% or fewer in Maine, Vermont, and West Virginia to 50% or more of the population in California, District of Columbia, Georgia, Hawaii, Maryland, Nevada, New Mexico, and Texas. Most people of color live in the South and West. More than half (59%) of the Black population resides in the South, and nearly eight in ten Hispanic people live in the West (38%) or South (39%). About three quarters of the NHPI population (75%), almost half (49%) of the AIAN population, and 43% of the Asian population live in the Western region of the country.

People of Color as a Share of the Total Population by State, 2022

TOTAL POPULATION BY AGE, RACE, AND ETHNICITY

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People of color are younger compared to White people. Hispanic people are the youngest racial and ethnic group, with 31% ages 18 or younger and 56% below age 35 (Figure 4). Roughly half of Black (48%), AIAN (50%), and NHPI (51%) people are below age 35, compared to 42% of Asian people and 38% of White people.

Total Population by Age and Race and Ethnicity, 2022

Health Coverage, Access to and Use of Care

RACIAL DISPARITIES IN HEALTH COVERAGE, ACCESS, AND USE

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Overall, Hispanic and AIAN people fare worse compared to White people across most examined measures of health coverage, and access to and use of care (Figure 5). Black people fare worse than White people across half of these measures, and experiences for Asian people are mostly similar to or better than White people across these examined measures. NHPI people fare worse than White people across some measures, but several measures lacked sufficient data for a reliable estimate for NHPI people.

Coverage, Access, and Use of Care Among People of Color Compared to White People

HEALTH COVERAGE

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Despite gains in health coverage across racial and ethnic groups over time, nonelderly AIAN, Hispanic, NHPI, and Black people remain more likely to be uninsured compared to their White counterparts. After the Affordable Care Act (ACA), Medicaid, and Marketplace coverage expansions took effect in 2014, all racial and ethnic groups experienced large increases in coverage. Beginning in 2017, coverage gains began reversing and the number of uninsured people increased for three consecutive years. However, between 2019 and 2022, there were small gains in coverage across most racial and ethnic groups, with pandemic enrollment protections in Medicaid and enhanced ACA premium subsidies. Despite these gains over time, disparities in health coverage persist as of 2022. Nonelderly AIAN (19%) and Hispanic (18%) people have the highest uninsured rates (Figure 6). Uninsured rates for nonelderly NHPI (13%) and Black (10%) people are also higher than the rate for their White counterparts (7%). Nonelderly White (7%) and Asian (6%) people have the lowest uninsured rates.

Uninsured Rate Among the Nonelderly Population by Race and Ethnicity, 2010-2022

ACCESS TO AND USE OF CARE

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Most groups of nonelderly adults of color are more likely than nonelderly White adults to report not having a usual doctor or provider and going without care. Roughly one third (36%) of Hispanic adults, one quarter of AIAN (25%) and NHPI (24%) adults, and about one in five (21%) Asian adults report not having a personal health care provider compared to 17% of White adults (Figure 7). The share of Black adults who report not having a personal health care provider is the same as their White counterparts (17% for both). In addition, Hispanic (21%), NHPI (18%), AIAN (16%), and Black (14%) adults are more likely than White adults (11%) to report not seeing a doctor in the past 12 months because of cost, while Asian adults (8%) are less likely than White adults to say they went without a doctor visit due to cost. Hispanic (32%) and AIAN (31%) adults are more likely than White adults (28%) to say they went without a routine checkup in the past year, while Asian (26%), NHPI (24%), and Black (20%) adults are less likely to report going without a checkup. Hispanic and AIAN (both 45%) and Black (40%) adults are more likely than White adults (34%) to report going without a visit to a dentist or dental clinic in the past year.

Percent of Nonelderly Adults Without a Personal Health Care Provider by Race and Ethnicity, 2022

In contrast to the patterns among adults, racial and ethnic differences in access to and use of care are more mixed for children. Nearly one in ten (9%) Hispanic children lack a usual source of care when sick compared to 5% of White children, but there are no significant differences for other groups for which data are available (Figure 8). Similar shares of Hispanic (7%), Asian (7%), and Black (4%) children went without a health care visit in the past year as White children (6%). However, higher shares of Asian (23%) and Black (21%) children went without a dental visit in the past year compared to White children (17%). Data are not available for NHPI children for these measures, and data for AIAN children should be interpreted with caution due to small sample sizes and large standard errors.

Percent of Children Without a Usual Source of Care When Sick Other Than the Emergency Room by Race and Ethnicity, 2022

Among adults with any mental illness, Black, Hispanic, and Asian adults are less likely than White adults to report receiving mental health services. Roughly half (56%) of White adults with any mental illness report receiving mental health services in the past year. (Figure 9). In contrast, about four in ten (40%) Hispanic adults and just over a third of Black (38%) and Asian (36%) adults with any mental illness report receiving mental health care in the past year. Data are not available for AIAN and NHPI adults.

Percent of Adults with Any Mental Illness Who Received Mental Health Services in the Past Year by Race and Ethnicity, 2022

Experiences across racial and ethnic groups are mixed regarding receipt of recommended cancer screenings (Figure 10). Among women ages 50-74 (the age group recommended for screening prior to updates in 2024, which lowered the starting age to 40), Black people (24%) are less likely than White people (29%) to go without a recent mammogram. In contrast, AIAN (41%) and Hispanic (35%) people are more likely than White people (29%) to go without a mammogram. Among those recommended for colorectal cancer screening, Hispanic, Asian, AIAN, NHPI, and Black people are more likely than White people to not be up to date on their screening. Increases in cancer screenings, particularly for breast, colorectal, and prostate cancers, have been identified as one of the drivers of the decline in cancer mortality over the past few decades.

Percent of Females Ages 50-74 Who did not Receive a Mammogram in Past 2 Years by Race and Ethnicity, 2022

Racial and ethnic differences persist in flu and childhood vaccinations (Figure 11). Roughly six in ten Hispanic (63%), AIAN (63%), and Black (58%) adults went without a flu vaccine in the 2022-2023 season compared to about half (49%) of White adults. However, among children, White children (44%) are more likely than Asian (28%) and Hispanic (39%) children to go without the flu vaccine; data are not available to assess flu vaccinations among NHPI adults and children. In 2019-2020, AIAN (42%), Black (37%), and Hispanic (33%) children were more likely than White children (28%) to have not received all recommended childhood immunizations.

Percent of Adults Who Did Not Receive a Flu Vaccine in the 2022-2023 Season by Race and Ethnicity

Health Status and Outcomes

RACIAL DISPARITIES IN HEALTH STATUS AND OUTCOMES

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Black and AIAN people fare worse than White people across the majority of examined measures of health status and outcomes (Figure 12). In contrast, Asian and Hispanic people fare better than White people for a majority of examined health measures. Nearly half of the examined measures did not have data available for NHPI people, limiting the ability to understand their experiences. Among available data, NHPI people fare worse than White people for more than half of the examined measures.   

Health Status and Outcomes Among People of Color Compared to White People

LIFE EXPECTANCY

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AIAN and Black people have a shorter life expectancy at birth compared to White people, and AIAN, Hispanic, and Black people experienced larger declines in life expectancy than White people between 2019 and 2021. Life expectancy at birth represents the average number of years a group of infants would live if they were to experience the age-specific death rates prevailing during a specified period. Life expectancy declined by 2.7 years between 2019 and 2021, largely reflecting an increase in excess deaths due to COVID-19, which disproportionately impacted Black, Hispanic, and AIAN people. AIAN people experienced the largest life expectancy decline of 6.6 years, followed by Hispanic (4.2 years) and Black people (4.0 years), and a smaller decline of 2.4 years for White people. Asian people had the smallest decline in life expectancy of 2.1 years between 2019 and 2021. Provisional data from 2022 show that overall life expectancy increased across all racial and ethnic groups between 2021 and 2022, but racial disparities persist (Figure 13). Life expectancy is lowest for AIAN people at 67.9 years, followed by Black people at 72.8 years, while White and Hispanic people have higher life expectancies of 77.5 and 80 years, respectively, and Asian people have the highest life expectancy at 84.5 years. Life expectancies are even lower for AIAN and Black males, at 64.6 and 69.1 years, respectively. Data are not available for NHPI people.

Life Expectancy at Birth in Years by Race and Ethnicity, 2019-2022

SELF-REPORTED HEALTH STATUS

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Black, Hispanic, and AIAN adults are more likely to report fair or poor health status than their White counterparts, while Asian adults are less likely to indicate fair or poor health. Nearly three in ten (29%) AIAN adults and roughly two in ten Hispanic (23%) and Black (21%) adults report fair or poor health status compared to 16% of White adults (Figure 14). One in ten Asian adults report fair or poor health status.

Percent of Adults Reporting Fair or Poor Health Status by Race and Ethnicity, 2022

BIRTH RISKS AND OUTCOMES

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NHPI (62.8 per 100,000), Black (39.9 per 100,000), and AIAN (32 per 100,000) women have the highest rates of pregnancy-related mortality (deaths within one year of pregnancy) between 2017-2019, while Hispanic women (11.6 per 100,000) have the lowest rate (Figure 15). More recent data for maternal mortality, which measures deaths that occur during pregnancy or within 42 days of pregnancy, shows that Black women (49.5 per 100,000) have the highest maternal mortality rate across racial and ethnic groups in 2022 (Figure 16). However, maternal mortality rates decreased significantly across most racial and ethnic groups between 2021 and 2022. Experts suggest the decline may reflect a return to pre-pandemic levels following the large increase in maternal death rates due to COVID-19 related deaths. The Dobbs decision eliminating the constitutional right to abortion could widen the already large disparities in maternal health as people of color may face disproportionate challenges accessing abortions due to state restrictions.

Pregnancy-Related Mortality per 100,000 Births by Race and Ethnicity, 2017-2019
Maternal Mortality per 100,000 Births by Race and Ethnicity, 2018-2022

Black, AIAN, and NHPI women have higher shares of preterm births, low birthweight births, or births for which they received late or no prenatal care compared to White women (Figure 17). Additionally, Asian women are more likely to have low birthweight births than White women. Notably, NHPI women (22%) are four times more likely than White women (5%) to begin receiving prenatal care in the third trimester or to receive no prenatal care at all.

Preterm Birth Rate by Race and Ethnicity, 2022

Teen birth rates have declined over time, but the birth rates among Black, Hispanic, AIAN, and NHPI teens are over two times higher than the rate among White teens (Figure 18). In contrast, the birth rate for Asian teens is more than four times lower than the rate for White teens.

Birth Rate per 1,000 for Teens Ages 15-19 by Race and Ethnicity, 2022

Infants born to women of color are at higher risk for mortality compared to those born to White women. Infant mortality rates have declined over time although provisional 2022 data suggest a slight increase relative to 2021. As of 2022, Black (10.9 per 1,000) and AIAN (9.1 per 1,000) infants are at least two times as likely to die as White infants (4.5 per 1,000) (Figure 19). NHPI infants (8.5 per 1,000) are nearly twice as likely to die as White infants (4.5 per 1,000). Asian infants have the lowest mortality rate at 3.5 per 1,000 live births.

Infant Mortality per 1,000 Live Births by Race and Ethnicity, 2022

HIV AND AIDS DIAGNOSIS INDICATORS

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Black, Hispanic, NHPI, and AIAN people are more likely than White people to be diagnosed with HIV or AIDS, the most advanced stage of HIV infection. In 2021, the HIV diagnosis rate for Black people is roughly eight times higher than the rate for White people, and the rate for Hispanic people is about four times higher than the rate for White people (Figure 20). AIAN and NHPI people also have higher HIV diagnosis rates compared to White people. Similar patterns are present in AIDS diagnosis rates, the most advanced stage of HIV, reflecting barriers to treatment. Black people have a roughly nine times higher rate of AIDS diagnosis compared to White people, and Hispanic, AIAN, and NHPI people also have higher rates of AIDS diagnoses. Most groups have seen decreases in HIV and AIDS diagnosis rates since 2013, although the HIV diagnosis rate has remained stable for Hispanic people and increased for AIAN and NHPI people.

HIV Diagnosis per 100,000 Among Teens and Adults by Race and Ethnicity, 2021

Among people ages 13 and older living with diagnosed HIV infection, viral suppression rates are lower among AIAN (64%), Hispanic (64%), NHPI (63%), and Black (62%) people compared with White (72%) and Asian (70%) people (Figure 21). Viral suppression refers to having less than 200 copies of HIV per milliliter of blood. Increasing the viral suppression rate among people with HIV is one of the key strategies of the Ending the HIV Epidemic in the U.S. initiative. Viral suppression promotes optimal health outcomes for people with HIV and also offers a preventive benefit as when someone is virally suppressed, they cannot sexually transmit HIV.

Viral Suppression Rates Among People Ages 13 Years and Older Living with Diagnosed HIV Infection by Race and Ethnicity, 2021

CHRONIC DISEASE AND CANCER

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The prevalence of chronic disease varies across racial and ethnic groups and by type of disease. Diabetes rates for AIAN (18%), Black (16%), and Hispanic (13%) adults are all higher than the rate for White adults (11%). AIAN people (11%) are more likely to have had a heart attack or heart disease than White people (8%), while rates for Black (6%), NHPI (6%), Hispanic (4%) and Asian (3%) people are lower than White people. Black (12%) and AIAN (13%) adults have higher rates of asthma compared to their White counterparts (10%), while rates for Hispanic (8%) and Asian (5%) adults are lower, and the rate for NHPI is the same (10%). Among children, Black children (16%) are nearly twice as likely to have asthma compared to White children (9%), while Asian children (6%) have a lower asthma rate (Figure 22). Differences are not significant for other racial and ethnic groups, and data are not available for NHPI children.

Percent of Adults Told by Doctor They Have Diabetes by Race and Ethnicity, 2022

AIAN, NHPI, and Black people are roughly twice as likely as White people to die from diabetes, and Black people are more likely than White people to die from heart disease (Figure 23). Hispanic people (28.3 per 100,000) also have a higher diabetes death rate compared to White people (21.3 per 100,000). In contrast, Asian people (17.2 per 100,000) are less likely than White people (21.3 per 100,000) to die from diabetes, and AIAN, Hispanic, and Asian people have lower heart disease death rates than their White counterparts.

Age-Adjusted Death Rates per 100,000 for Selected Diseases by Race and Ethnicity, 2022

People of color generally have lower rates of new cancer cases compared to White people, but Black people have higher incidence rates for some cancer types (Figure 24). Black people have lower rates of cancer incidence compared to White people for cancer overall, and most of the leading types of cancer examined. However, they have higher rates of new colon, and rectum, and prostate cancer. AIAN people have a higher rate of colon and rectum cancer than White people. Other groups have lower cancer incidence rates than White people across all examined cancer types.

Age-Adjusted Rate of Cancer Incidence per 100,000 by Race and Ethnicity, 2020

Although Black people do not have higher cancer incidence rates than White people overall and across most types of cancer, they are more likely to die from cancer. Black people have a higher cancer death rate than White people for cancer overall and for most of the leading cancer types (Figure 25). In contrast, Hispanic, Asian and Pacific Islander, and AIAN people have lower cancer mortality rates across most cancer types compared to White people. The higher mortality rate among Black people despite similar or lower rates of incidence compared to White people could reflect a combination of factors, including more limited access to care, later stage of diagnosis, more comorbidities, and lower receipt of guideline-concordant care, which are driven by broader social and economic inequities.

Age-Adjusted Rate of Cancer Mortality per 100,000 by Race and Ethnicity, 2020

COVID-19 DEATHS

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AIAN, Hispanic, NHPI, and Black people have higher rates of COVID-19 deaths compared to White people. As of March 2024, provisional age-adjusted data from the Centers for Disease Control and Prevention (CDC) show that between 2020 and 2023, AIAN people are roughly two times as likely as White people to die from COVID-19, and Hispanic, NHPI and Black people are about 1.5 times as likely to die from COVID-19 (Figure 26). Asian people have lower COVID-19 death rates during this period compared to all other race and ethnicity groups.

Age-Adjusted Rates of COVID-19 Deaths per 100,000 by Race and Ethnicity, 2020-2023

OBESITY

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Obesity rates vary across race and ethnicity groups. As of 2022, Black (43%), AIAN (39%), and Hispanic (37%) adults all have higher obesity rates than White adults (32%), while Asian adults (13%) have a lower obesity rate (Figure 27).

Obesity Rate Among Adults by Race and Ethnicity, 2022

Mental Health and Drug Overdose Deaths

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Overall rates of mental illness are lower for people of color compared to White people but could be underdiagnosed among people of color. About one in five Hispanic and Black (21% and 20%, respectively) adults and 17% of Asian adults report having a mental illness compared to 25% of White adults (Figure 28). Among adolescents, the share with symptoms of a past year major depressive episode were not significantly different across racial and ethnic groups, with roughly one in five White (21%) and Hispanic (20%) adolescents, 17% of Black, and about one in seven Asian (15%), and AIAN (14%) adolescents reporting symptoms. Data are not available for NHPI people. Research suggests that a lack of culturally sensitive screening tools that detect mental illness, coupled with structural barriers could contribute to underdiagnosis of mental illness among people of color.

Percent of Adults with Any Mental Illness by Race and Ethnicity, 2022

AIAN and White people have the highest rates of deaths by suicide as of 2022. People of color have been disproportionately affected by recent increases in deaths by suicide compared with their White counterparts. As of 2022, AIAN (27.1 per 100,000) and White (17.6 per 100,000) people have the highest rates of deaths by suicide compared to all other racial and ethnic groups (Figure 29). Rates of deaths by suicide are also over three times higher among AIAN adolescents (32.9 per 100,000) than White adolescents (10.6 per 100,000). In contrast, Black, Hispanic, and Asian adolescents have lower rates of suicide deaths compared to their White peers.

Suicide Death Rate per 100,000 Population by Race and Ethnicity, 2022

Drug overdose death rates increased among AIAN, Black, Hispanic, and Asian people between 2021 and 2022. As of 2022, AIAN people continue to have the highest rates of drug overdose deaths (65.2 per 100,000 in 2022) compared with all other racial and ethnic groups. Drug overdose death rates among Black people (47.5 per 100,000) exceed rates for White people (35.6 per 100,000), reflecting larger increases among Black people in recent years (Figure 30). Hispanic (22.7 per 100,000), NHPI (18.8 per 100,000), and Asian (5.3 per 100,000) people have lower rates of drug overdose deaths than White people (35.6 per 100,000). Data on drug overdose deaths among adolescents show that while White adolescents account for the largest share of drug overdose deaths, Black and Hispanic adolescents have experienced the fastest increase in these deaths in recent years.

Age-Adjusted Drug Overdose Deaths per 100,000, by Race and Ethnicity

Social Determinants of Health

RACIAL DISPARITIES IN SOCIAL AND ECONOMIC FACTORS

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Social determinants of health are the conditions in which people are born, grow, live, work, and age. They include factors like socioeconomic status, education, immigration status, language, neighborhood and physical environment, employment, and social support networks, as well as access to health care. There has been extensive research and recognition that addressing social, economic, and environmental factors that influence health is important for advancing health equity. Research also shows how racism and discrimination drive inequities across these factors and impact health and well-being.  

Black, Hispanic, AIAN, and NHPI people fare worse compared to White people across most examined measures of social determinants of health (Figure 31). Experiences for Asian people are more mixed relative to White people across these examined measures. Reliable or disaggregated data for NHPI people are missing for a number of measures.

Social Determinants of Health among People of Color Compared to White People

WORK STATUS, FAMILY INCOME, AND EDUCATION

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Across racial and ethnic groups, most nonelderly people live in a family with a full-time worker, but Black, Hispanic, AIAN, and NHPI nonelderly people are more likely than White people to be in a family with income below poverty (Figure 32). While most people across racial and ethnic groups live in a family with a full-time worker, disparities persist. AIAN (68%), Black (73%), NHPI (77%), and Hispanic (81%) people are less likely than White people (83%) to have a full-time worker in the family. In contrast, Asian people (86%) are more likely than their White counterparts (83%) to have a full-time worker in the family. Despite the majority of people living in a family with a full-time worker, over one in five AIAN (25%) and Black (22%) people have family incomes below the federal poverty level, over twice the share as White people (10%), and rates of poverty were also higher among Hispanic (17%) and NHPI (16%) people.

Percent of the Nonelderly Population With a Full-Time Worker in the Family by Race and Ethnicity, 2022

Black, Hispanic, AIAN, and NHPI people have lower levels of educational attainment compared to their White counterparts. Among people ages 25 and older, over two thirds (69%) of White people have completed some post-secondary education, compared to less than half (45%) of Hispanic people, just over half of AIAN and NHPI people (both at 52%), and about six in ten Black people (58%) (Figure 33). Asian people are more likely than White people to have completed at least some post-secondary education, with 74% completing at least some college.

Educational Attainment by Race and Ethnicity, 2022

NET WORTH AND HOME OWNERSHIP

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Black and Hispanic families have less wealth than White families. Wealth can be defined using net worth, a measure of the difference between a family’s assets and liabilities. The median net worth for White households is $285,000 compared to $44,900 for Black households and $61,600 for Hispanic households (Figure 34). Asian households have the highest median net worth of $536,000. Data are not available for AIAN and NHPI people.

Family Median Net Worth by Race and Ethnicity, 2022

People of color are less likely to own a home than White people (Figure 35). Nearly eight in ten (77%) White people own a home compared to 70% of Asian people, 62% of AIAN people, 55% of Hispanic people, and about half of Black (49%) and NHPI (48%) people.

Home Ownership Rate by Race and Ethnicity, 2022

FOOD SECURITY, HOUSING QUALITY, AND INTERNET ACCESS

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Black and Hispanic adults and children are more likely to experience food insecurity compared to their White counterparts. Among adults, AIAN (18%), Black (14%), and Hispanic (12%) adults report low or very low food security compared to White adults (6%) (Figure 36). Among children, AIAN (24%), Black (21%) and Hispanic (15%) children are over twice as likely to be food insecure than White children (6%). Data are not available for NHPI adults and children.

Percent of Adults With Food Insecurity, 2022

People of color are more likely to live in crowded housing than their White counterparts (Figure 37). Among White people, 3% report living in a crowded housing arrangement, that is having more than one person per room, as defined by the American Community Survey. In contrast, almost three in ten (28%) NHPI people, roughly one in five (18%) Hispanic people, 16% AIAN people, and about one in ten Asian (12%) and Black (8%) people report living in crowded housing.

Percent of Individuals Living in Crowded Housing by Race and Ethnicity, 2022

AIAN, NHPI, and Black people are less likely to have internet access than White people (Figure 38). Higher shares of AIAN (12%), and Black and NHPI people (both at 6%) say they have no internet access compared to their White counterparts (4%). In contrast, Asian people (2%) are less likely to report no internet access than White people (4%).

	Percent of Individuals Without Internet Access by Race and Ethnicity, 2022

TRANSPORTATION

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People of color are more likely to live in a household without access to a vehicle than White people (Figure 39). About one in eight Black people (12%) and about one in ten AIAN (9%) and Asian (8%) people live in a household without a vehicle available followed by 7% of Hispanic and NHPI people. White people are the least likely to report not having access to a vehicle in the household (4%).

Percent of Individuals Living in a Household Without Vehicle Access by Race and Ethnicity, 2022

CITIZENSHIP AND ENGLISH PROFICIENCY

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Asian, Hispanic, NHPI, and Black people include higher shares of noncitizen immigrants compared to White people. Asian and Hispanic people have the highest shares of noncitizen immigrants at 25% and 19%, respectively (Figure 40). Asian people are projected to become the largest immigrant group in the United States by 2055. Immigrants are more likely to be uninsured than citizens and face increased barriers to accessing health care.

Percent of Total Population Who is a Noncitizen by Race and Ethnicity, 2022

Hispanic and Asian people are more likely to have LEP compared to White people. Almost one in three Asian (31%) and Hispanic (28%) people report speaking English less than very well compared to White people (1%)(Figure 41). Adults with LEP are more likely to report worse health status and increased barriers in accessing health care compared to English proficient adults.

Percent of Individuals Ages Five and Older Who have Limited English Proficiency by Race and Ethnicity, 2022

EXPERIENCES WITH RACISM, DISCRIMINATION, AND UNFAIR TREATMENT

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Racism is an underlying driver of health disparities, and repeated and ongoing exposure to perceived experiences of racism and discrimination can increase risks for poor health outcomes. Research has shown that exposure to racism and discrimination can lead to negative mental health outcomes and certain negative impacts on physical health, including depression, anxiety, and hypertension.

Black, AIAN, Hispanic, and Asian adults are more likely to report certain experiences with discrimination in daily life compared with their White counterparts, with the greatest frequency reported among Black and AIAN adults. A 2023 KFF survey shows that at least half of AIAN (58%), Black (54%), and Hispanic (50%) adults and about four in ten (42%) Asian adults say they experienced at least one type of discrimination in daily life in the past year (Figure 42). These experiences include receiving poorer service than others at restaurants or stores; people acting as if they are afraid of them or as if they aren’t smart; being threatened or harassed; or being criticized for speaking a language other than English. Data are not available for NHPI adults.

Percent of People Who Report Experiences of Discrimination by Race and Ethnicity, 2023

About one in five (18%) Black adults and roughly one in eight AIAN (12%) adults, followed by roughly one in ten Hispanic (11%), and Asian (10%) adults who received health care in the past three years report being treated unfairly or with disrespect by a health care provider because of their racial or ethnic background. These shares are higher than the 3% of White adults who report this (Figure 43). Overall, roughly three in ten (29%) AIAN adults and one in four (24%) Black adults say they were treated unfairly or with disrespect by a health care provider in the past three years for any reason compared with 14% of White adults.

Percent of People Who Report Experiences of Discrimination by a Health Care Provider by Race and Ethnicity, 2023

About the Data

Data Sources

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This chart pack is based on the KFF Survey on Racism, Discrimination, and Health and KFF analysis of a wide range of health datasets, including the 2022 American Community Survey, the 2022 Behavioral Risk Factor Surveillance System, the 2022 National Health Interview Survey, the 2022 National Survey on Drug Use and Health, and the 2022 Survey of Consumer Finances as well as from several online reports and databases including the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) on vaccination coverage, the National Center for Health Statistics (NCHS) National Vital Statistics Reports, the CDC Influenza Vaccination Dashboard Flu Vaccination Coverage Webpage Report, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, the United States Cancer Statistics Incidence and Mortality Web-based Report, the 2022 CDC Natality Public Use File, CDC Web-based Injury Statistics Query and Reporting System (WISQARS) database, and the CDC WONDER online database.

Methodology

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Unless otherwise noted, race/ethnicity was categorized by non-Hispanic White (White), non-Hispanic Black (Black), Hispanic, non-Hispanic American Indian and Alaska Native (AIAN), non-Hispanic Asian (Asian), and non-Hispanic Native Hawaiian or Pacific Islander (NHPI). Some datasets combine Asian and NHPI race categories limiting the ability to disaggregate data for these groups. Non-Hispanic White persons were the reference group for all significance testing. All noted differences were statistically significant differences at the p<0.05. We include data for smaller population groups wherever available. Instances in which the unweighted sample size for a subgroup is less than 50 or the relative standard error is greater than 30% are noted in the figures, and confidence intervals for those measures are included in the figure.

News Release

Walgreens and KFF’s Greater Than HIV Join with Community Partners to Offer Free HIV and STD Testing at Record Number of Stores on June 27

The Collaboration Is The Largest National HIV Testing Day Event in the Nation

Published: Jun 11, 2024

DEERFIELD, Ill. & SAN FRANCISCO, June 11, 2024 – Walgreens and Greater Than HIV, a public information initiative of KFF, are teaming up with health departments and community organizations to offer free rapid HIV testing in more than 550 Walgreens stores on June 27 in the largest coordinated National HIV Testing Day event.

Additionally, to address the rising rates of other sexually transmitted diseases (STDs), free rapid syphilis and/or hepatitis C testing will also be offered by partners this year in many locations.

“This unique public-private partnership brings free rapid HIV and STD testing directly to communities in a familiar setting and connects individuals to trusted local prevention and treatment service providers in their area,” said Tina Hoff, senior vice president, KFF.

A list of participating Walgreens stores and hours when free HIV and STD testing will be offered is available here; no appointment needed. Testing is provided by local partners, in a private area of the store or mobile unit, with results available in 20 minutes or less. Counselors can also answer questions about HIV and STDs and provide the latest on prevention and treatment options, including referrals for PrEP (pre-exposure prophylaxis), FDA-approved medications that are highly effective in preventing HIV, and other needed care.

“This program is instrumental in reaching people in community settings, making HIV prevention and treatment options more equitable, accessible and convenient,” said Rick Gates, chief pharmacy officer, Walgreens. “In addition to providing services to help prevent and treat HIV for more than 40 years, Walgreens invests in training its pharmacy team members to address the specific challenges faced by people living with HIV – including confidential medication counseling, information on prevention options and how to apply for financial assistance programs.”

Major HIV rapid test manufacturers including Abbott Laboratories, BioLytical Laboratories, ChemBio Diagnostics, and OraSure Technologies donated tests to support this year’s effort. Additionally, ChemBio Diagnostics and Diagnostics Direct donated rapid syphilis tests.

Since 2011, KFF’s Greater Than HIV and Walgreens National HIV Community Partnership has provided more than 82,000 free HIV tests through the in-store NHTD program, including over 15,000 self-tests distributed during the height of the COVID-19 pandemic. This is the 14th year of the partnership and marks the highest level of participation – both in terms of testing partners and stores – in the program’s history.

About Walgreens

Walgreens (www.walgreens.com) is included in the U.S. Retail Pharmacy and U.S. Healthcare segments of Walgreens Boots Alliance, Inc. (Nasdaq: WBA), an integrated healthcare, pharmacy and retail leader. True to its purpose of “more joyful lives through better health,” Walgreens has a more than 120-year heritage of caring for communities and providing trusted pharmacy services, and today is playing a greater role as an independent partner of choice offering healthcare services that improve care, lower costs, and help patients. Operating nearly 9,000 retail locations across the U.S. and Puerto Rico, Walgreens is proud to serve nearly 9 million customers and patients daily. The company’s pharmacists are playing a more critical role in healthcare than ever before, providing a wide range of pharmacy and healthcare services, including those that drive equitable access to care for some of the nation’s most underserved populations. Walgreens offers customers and patients a true omnichannel experience, with fully integrated physical and digital platforms designed to deliver high-quality products and healthcare services. Within the U.S. Healthcare segment, Walgreens portfolio also includes businesses in primary care, multi-specialty, post-acute care, urgent care, specialty pharmacy services, population health and provider enablement.

About KFFKFF is the independent source for health policy research, polling, and journalism. Its mission is to serve as a nonpartisan source of information for policymakers, the media, the health policy community, and the public.  

KFF’s Greater Than HIV initiative is a leading public information response focused on HIV in the U.S. Through localized Greater Than HIV campaigns, KFF works with health departments and community partners to reach those most affected and in need with the latest on testing, prevention and treatment. This public-private partnership model helps extend the reach of limited resources in high need areas.

A Review of Exceptions in State Abortion Bans: Implications for the Provision of Abortion Services

Authors: Mabel Felix, Laurie Sobel, and Alina Salganicoff
Published: Jun 6, 2024

Issue Brief

Note: Originally published in May 2023, this brief has been updated and expanded to address ongoing litigation in many states that is underway to challenge exceptions laws.

Key Takeaways

Abortion is currently banned in 14 states and many other states have attempted to ban or severely restrict access to abortion. All of these bans have an exception to prevent the death of the pregnant person and some bans include other exceptions that fall into three categories: when there is risk to the health of the pregnant person, when the pregnancy is the result of rape or incest, and when there is a lethal fetal anomaly.

  • In practice, health and life exceptions to bans have often proven to be unworkable, except in the most extreme circumstances, and have sometimes prevented physicians from practicing evidence-based medicine.
  • Abortion bans and restrictions have led physicians to delay providing miscarriage management care. Many states allow for the removal of a dead fetus or embryo, but pregnant people who are actively miscarrying may be denied care if there is still detectable fetal cardiac activity or until the miscarriage puts the life of the pregnant person in jeopardy.
  • Mental health exceptions are rare despite the fact that 20% of pregnancy-related deaths are attributable to mental health conditions.
  • Law enforcement involvement is often required to document rape and incest, which often prevents survivors from accessing abortion care. Furthermore, survivors in states where abortion care is restricted can have difficulty finding an abortion provider.
  • In many states there is more than one abortion ban in the books, and in some of those states, the exception provisions in the bans are often at odds with each other. These multiple bans and varying exceptions create confusion among patients and providers.

Introduction

Since the Supreme Court’s Dobbs decision overturned Roe v. Wade, state abortion bans and the exceptions they contain – or lack – have garnered significant attention. The Supreme Court is considering a case this term about whether the Emergency Medical Treatment and Active Labor Act (EMTALA), a federal law requiring hospitals to provide stabilizing treatment to patients who present to their emergency rooms, preempts state abortion laws and requires hospitals to provide abortion care when it is necessary to stabilize a patient, even when the abortion does not qualify foris not including in an exception to the state’s abortion ban. Discussions about exceptions to state abortion bans often obscure the reality that many of these exceptions can be unworkable in practice. There are reports of people being unable to obtain abortions, despite the fact that their pregnancies fall into these broad exception categories. While there is no accurate estimate of the number of people seeking abortion care in circumstances that qualify for an exception in states than ban abortion, the number of people who have received abortion care post-Dobbs in states that have banned abortion is very low.  Many of the exceptions included in these bans use definitions that are vague, narrow, and non-clinical, and effectively remove the ability of health care providers to best manage the care of pregnant people, instead leaving that decision to the state or the clinician’s home institution. Further complicating matters, several states have multiple bans in effect, often with contradicting definitions, requirements, exceptions, and standards, creating ambiguity for clinicians and their patients. This brief analyzes the exceptions to abortion bans and discusses how their purported aims to provide life-saving care may not be achieved in practice.

What kinds of exceptions do abortion bans contain?

Exceptions to state abortion bans generally fall into four general categories: to prevent the death of the pregnant person, to preserve the health of the pregnant person, when the pregnancy is the result of rape or incest, and when the embryo or fetus has lethal anomalies incompatible with life.

States with Abortion Bans and Restrictions with Exceptions for Life

To prevent the death of the pregnant person

All state abortion bans currently in effect contain exceptions to “prevent the death” or “preserve the life” of the pregnant person. As explained in further detail in the section below, these exceptions may create difficulties for physicians, as it is unclear how much risk of death or how close to death a pregnant patient may need to be for the exception to apply and the determination is not up to the physician treating the pregnant patient.

When there is risk to the health of the pregnant person

Many state bans currently in effect – with the exception of bans in Arkansas, Idaho, Mississippi, Oklahoma, South Dakotan, and Texas – contain some form of health exception. Exceptions to preserve the health of the pregnant person can vary (sometimes significantly) from state to state (Table 1).

Language in health exceptions to abortion bans

Most states with bans that contain a health exception permit abortion care when there is a serious risk of substantial and irreversible impairment of a major bodily function. These exceptions are limited by the lack of specific clinical definitions of the conditions qualifying for the exception. Only the Arizona 15-week LMP (last menstrual period) limit explicitly defines the bodily functions that may be considered “major.”  The other states that use this language in their bans do not define what constitutes a “major bodily function,” nor what constitutes a “substantial impairment” to a major bodily function. This vague language puts physicians providing care to pregnant people in a difficult situation should their patients need an abortion to treat a condition jeopardizing their health and can leave the determination of whether an abortion can be legally provided to lawyers for the institution in which the clinician practices. For instance, in South Carolina where the 6-week LMP abortion limit has a health exception, the law lists a couple of conditions that may fall under this exception, such as severe pre-eclampsia and uterine rupture, but with no further detail. Using this language as guidance, it would be difficult for physicians to know if a significant health issue would fall under the exception. The difficulties presented by the simultaneous vagueness and narrowness of the exceptions are exacerbated by the lack of deference given to clinicians’ medical judgment under these bans.

However, even if the terms in the exceptions were defined more clearly, they would still exclude many health conditions pregnant people face. In Georgia, for example, providers challenging the ban note that the exceptions do not permit abortion care when it is needed to prevent: “(1) substantial but reversible physical impairment of a major bodily function, (2) less than ‘substantial’ but irreversible physical impairment of a major bodily function, or (3) substantial and irreversible physical impairment of a bodily function that is not ‘major.’” A medical condition may still be a significant health event, yet not qualify under the exceptions, even if their limits were more clearly defined.

MENTAL HEALTH

Mental health conditions account for over 20% of pregnancy-related deaths in the US, yet almost all states with health exceptions limit them to conditions affecting physical health, with some going further and explicitly precluding emotional or psychological health conditions. Alabama, the only state that includes mental health concerns in its health exception, requires a psychiatrist to diagnose the pregnant person with a “serious mental illness” and document it is likely the person will engage in behavior that could result in their death or the death of the fetus that due to their mental health condition. The law does not define “serious mental illness” and does not allow physicians to determine what serious mental illnesses qualify for the exception. In addition, abortion bans and restrictions in Georgia, Florida, Idaho, Iowa, Kentucky, Louisiana, Nebraska, North Carolina, North Dakota, South Carolina, Tennessee, West Virginia, and Wyoming explicitly exclude mental/emotional health. Several other states (Texas, Oklahoma, Mississippi, the remaining Kentucky ban, and one of Arkansas’ total bans) limit their life and/or health exceptions to physical conditions, without explicitly calling out mental/emotional health exceptions.

ECTOPIC PREGNANCIES AND MISCARRIAGES

Some states’ abortion laws specify that care for ectopic pregnancies and pregnancy loss is not criminalized in its statutes. Most states with these provisions in their bans allow for the removal of a dead fetus or embryo, but not for miscarriage care, generally. This means that pregnant people who are actively miscarrying may be denied care if there is still detectable fetal cardiac activity. There have already been reports of such situations in Texas and Louisiana. In Louisiana, for example, a pregnant woman went to the hospital after experiencing sharp pain and bleeding. She was informed her fetus had likely stopped growing a few weeks prior, as its size did not correspond to the length of her pregnancy, and that it had very faint cardiac activity. Despite the pain and the blood loss she was experiencing, she could not receive the regimen of mifepristone and misoprostol commonly prescribed to pregnant patients who are miscarrying to ensure that the pregnancy is safely expelled from the body completely in a timely manner, thereby decreasing the risk of sepsis and infection. Instead, she had to wait for the miscarriage to progress without medical intervention, which would have expedited the process and reduced her medical risk. In states where the abortion bans do not clarify that miscarriage care is not criminalized – even when there is still detectable cardiac activity – pregnant people may not be able to receive care to manage their pregnancy loss unless and until it becomes a medical emergency.

GREATER RISK TO THE HEALTH OF PREGNANT PEOPLE

In deciding whether or not to provide abortion care to preserve the health of a pregnant patient, physicians now face the risk of a jury or the state disagreeing with their judgment about the gravity of the health risk the pregnant person was experiencing, and as a result, face prison time, monetary fines, and loss of professional license. Before the Supreme Court’s decision in Dobbs, the decision to have an abortion pre-viability when facing a health risk was made by the pregnant person in consultation with medical professionals in consideration of the needs and overall health history of the pregnant patient. In states with abortion bans, when deciding whether or not to provide abortion care to preserve the health of a pregnant patient, physicians now face the risk of prosecution, prison time, monetary fines, and loss of professional license.

In state court challenges against the bans, providers have argued that the vagueness of the bans is unconstitutional, since it places them in a situation where it is unclear how they might follow the law. As a result, physicians may be more reluctant to provide abortion care when pregnant patients present with serious medical conditions and may deny abortion care to pregnant people with conditions that threaten their health until their condition deteriorates and the narrow exceptions inarguably apply. This delay in care, however, creates greater and avoidable risks to the health of the pregnant person. Additionally, many conditions that threaten the health of pregnant people are not included in all or most health exceptions.

The difficulties these bans and their unclear exceptions create may additionally deter physicians from practicing medicine in states that ban abortion. There have already been reports of physicians expressing reluctance or refusing to relocate to these states, as well as physicians leaving these states due to their restrictive laws and fewer medical school graduates applying for residencies in these states. A substantial portion of these states’ residents already live in maternity deserts – areas where there are no obstetric providers or birth centers – and studies have shown that maternal mortality rates are higher in states that restrict abortion. Physicians being deterred from practicing in states with restrictive abortion laws may exacerbate these disparities in access to obstetric care and health outcomes.

Zurawski v. State of Texas

Five women who were denied abortion care in Texas ­- despite facing dangerous pregnancy complications – and two OB-GYNs filed a lawsuit in Texas state court asking the court to clarify the scope of the medical emergency exceptions in the state’s three abortion bans. Plaintiffs specifically asked the court to clarify that:

  • Physician judgment should be granted deference in measuring the risk the pregnant person is facing,
  • Impairment of a “major bodily function” includes harm to fertility and the reproductive system,
  • Acute risk does not have to be already present or imminent for the exceptions to apply, and
  • Health exceptions apply in situations where treatment for a condition is unsafe during pregnancy and for fetal conditions and diagnoses that can increase the risk to a pregnant person’s health.

Plaintiffs argued the misapplication of the health exceptions violates state constitutional guarantees to fundamental and equal rights. In August 2023, a County District Court judge issued an order blocking enforcement of Texas’ ban in situations where, in a physician’s good faith judgment, an abortion is needed due to an emergent medical situation. An appeal from the state to the Texas Supreme Court automatically blocked the lower court’s order. On May 31, 2024, the Texas Supreme Court issued its decision in this case, stating that the state’s abortion ban only contains exceptions when, in a physician’s reasonable medical judgment, there is a life-threatening physical condition.

THE EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT (EMTALA)

Enacted in 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) requires Medicare-enrolled hospitals to perform an appropriate medical screening examination to any patient who presents to their dedicated emergency department. If a patient is identified as having an emergency medical condition, the hospital must provide stabilizing treatment within the hospital’s capability or transfer the patient to another medical facility.

As states were starting to implement abortion bans after the Dobbs decision, in July 2022, the Department of Health and Human Services (HHS) issued guidance regarding the enforcement of EMTALA that clarifies hospitals and physicians have obligations to provide stabilizing care, including abortion in medically appropriate circumstances, when a patient presenting at an emergency department is experiencing an emergency medical condition.

After HHS issued this guidance, two lawsuits were filed. HHS sued the State of Idaho to block enforcement of Idaho’s abortion ban to the extent it conflicts with EMTALA, and the State of Texas sued to block enforcement of the HHS guidance in Texas. The Supreme Court is considering the case from Idaho and a decision is pending.

At stake in this case is whether EMTALA preempts state abortion laws and requires hospitals to provide abortion care when it is necessary to stabilize a patient’s condition, even when this abortion care violates state law. While all state abortion bans have an exception for pregnancies that jeopardize the life of a pregnant person, some do not have an exception that would allow an abortion to preserve the health of the pregnant person. Even in states with health exceptions, the exception might be very narrow and not well defined, leaving significant gaps in emergency medical care for pregnant people. EMTALA, however, requires hospitals to provide stabilizing care to patients with emergency medical conditions, including conditions that may harm their health. According to the HHS guidance issued in the wake of the Dobbs decision, EMTALA requires hospitals to provide abortion care to pregnant patients with emergency medical conditions when abortion is necessary to stabilize the patient’s condition. However, Idaho contends that EMTALA does not require hospitals to provide treatment that violates state law. The Court’s decision in this case could impact access to abortion in emergency situations across the country and potentially lay the foundation for future challenges involving state laws granting fetal personhood.

Exception vs. Affirmative Defense

Some state abortion bans lack exceptions but identify situations that may be used as an affirmative defense in court – among these are Tennessee’s 6-week LMP ban, Kentucky’s 15-week ban (but not the state’s earlier gestational bans), Texas’ total bans, and all of Missouri’s bans.  An “affirmative defense” allows someone charged with a crime to show in court that their conduct was permissible even though the action itself is illegal. An affirmative defense does not make it legal to provide abortion care in the situations delineated in the law and means that a clinician who provided abortion care is open to prosecution – regardless of the reason they provided an abortion – and would bear the burden of proof to demonstrate that they provided care according to the conditions delineated as possible affirmative defenses in the abortion ban. Bans that rely on an affirmative defense leave physicians more vulnerable to criminal prosecution and they make it even riskier for physicians to provide abortion care in situations where the life or health of the pregnant person is at risk.

Sexual Assault Exceptions

A few of the state abortion bans contain exceptions for pregnancies resulting from rape or incest, generally requiring that the sexual assault be reported to law enforcement. Some states allow for a Child Protective Services (CPS) report in lieu of a law enforcement report for minors who are survivors of sexual assault or incest.

It is well documented that survivors are often afraid to report sexual violence to the police due to fear of retaliation and the belief that law enforcement would not or could not do anything to help. It is estimated that only 21% of sexual assaults are reported to law enforcement. Even for survivors who do report to law enforcement, state abortion bans do not make clear exactly what information needs to be given to a provider to make it clear that the abortion would be legal in that state. Reporting requirements place barriers in the way of survivors seeking abortion care in these states.

Among the few sexual assault exceptions, some have specific gestational limits. For instance, the total ban currently in effect in West Virginia contains an exception for cases of rape or incest, but it is limited to 8 weeks from the last menstrual period (LMP) for adults and 14 weeks LMP for minors.

Although sexual assault exceptions are intended to protect survivors, experts agree that they rarely work. There is anecdotal evidence of survivors in states with rape exceptions and who have compiled the necessary documentation, but still not being able to access abortion because they couldn’t find any abortion providers in their state.

Hyde Amendment

The Hyde Amendment is a policy that restricts the use of federal funds to cover abortion, except in cases of rape or incest, or when the life of the pregnant person is endangered (Hyde Exceptions). The policy is not a permanent law, but rather has been attached as a temporary “rider” to the Congressional appropriations bill for the Department of Health and Human Services (HHS) and has been renewed annually by Congress. In the past, federal courts have interpreted the Hyde provisions to require states to pay for abortions that fall into the Hyde Exceptions and have blocked enforcement of state statutes that prohibit coverage for these cases. However, the enforceability of these requirements has been unclear since the Supreme Court’s decision in Dobbs. Although all bans currently in effect contain exceptions to safeguard the life of the pregnant person, most states with abortion bans do not have exceptions for cases of rape or incest, and therefore, would not allow for the provision or coverage of those services to Medicaid recipients, contrary to previous court orders. To date, no court or federal agency has issued orders or guidance on states’ obligation to provide coverage for Hyde Exceptions when their bans prohibit the provision of abortion in cases of rape or incest.

Lethal Fetal Anomaly Exceptions

Bans in several states contain exceptions for lethal fetal anomalies, usually limited to those anomalies that would result in the death of the baby at birth or soon after. As with health exceptions, lethal fetal anomaly exceptions are poorly defined and limited in statutes. The only state with this kind of exception that has a comprehensive list of conditions that fall under this category is Louisiana, but since the state has multiple abortion bans in effect (one of which does not include exceptions for fatal fetal anomalies), the applicability of this exception is still unclear. Other states, like Indiana, provide some general criteria, such as how long after birth the baby can be expected to live for a pregnancy to fall under the fetal anomaly. Any condition that would result in a life expectancy shorter than three months fits under the exception. The religious freedom lawsuit against the state’s ban – Anonymous Plaintiffs v. Medical Licensing Board of Indiana — specifically challenges the narrow limits of the exception, arguing that other common conditions, such as Tay-Sachs disease would result in the death very early in childhood.

What happens in states with more than one abortion ban in effect?

In many states there is more than one abortion ban in the books, and in some of those states, the exception provisions in the bans are at odds with each other. In Louisiana, two bans and a 15-week LMP limit are in effect, but only one of the total bans and the 15-week limit have the same exceptions; the remaining total ban does not. One of the total criminal bans in the state has exceptions to prevent the death or substantial risk of death, of the pregnant person and to prevent “serious, permanent impairment of a life-sustaining organ”. The state’s other total ban and the 15-week limit have exceptions for these same cases and additionally in cases of fatal fetal anomalies, and clarify that the bans’ prohibitions do not apply for ectopic pregnancies and miscarriages. The conflicting exceptions in the bans result in a situation where the only real exceptions in the state are for cases where an abortion is necessary to prevent the death of the pregnant person or to prevent serious, permanent impairment of a life-sustaining organ. Providing abortion care under any other exception in the states’ other total ban or 15-week limit would open physicians to criminal penalties and loss of license.

Mississippi is another state with multiple bans in effect that contain contradicting exceptions. The state’s total ban only has exceptions for cases when an abortion is necessary to preserve the life of the pregnant person or when the pregnancy was caused by rape (there is no exception for incest in the state). However, the state’s 15-week LMP ban contains exceptions for fatal fetal abnormalities and serious risk of substantial and irreversible impairment of a major bodily function, along with a life exception. In situations where there is more than one ban in effect, it might seem that the easiest way to follow the law would be to adhere to the abortion ban with the strictest gestational limit. This would not suffice in Mississippi, however, since the total ban contains an exception for pregnancies caused by rape, but the state’s 15-week LMP ban does not contain such an exception. Therefore, following any one of the state’s abortion bans would not remove the legal risk of providing abortion care in the state. Instead, providers must assess how the abortion bans and their exceptions work in conjunction.

Conclusion

Although a lot of attention has been devoted to debates about exceptions in abortion bans, many of these exceptions are not workable in practice. Outside of testimony from providers, it is difficult to assess how many people who qualify for abortion care under the exceptions are actually able to do so, since states underreport or do not report this information. However, it is apparent these bans create barriers to accessing abortion care, even in situations where the exceptions they outline should apply. Most importantly, these bans place the health and lives of pregnant people at risk by potentially preventing physicians from providing medically appropriate care. The Supreme Court’s decision in Idaho v. United States will determine whether EMTALA preempts state laws and requires hospitals to provide abortion care to stabilize pregnant patients when “necessary to assure that no material deterioration of the condition is likely to occur.” If the Court rules in favor of Idaho, the inability to provide evidence-based care may additionally make physicians reluctant to practice medicine in restrictive states, amplifying already-existing discrepancies in ability to access obstetric care and adverse maternal and fetal outcomes.

Appendix

Abortion Bans and Exceptions

How ACA Marketplace Premiums Changed by County in 2024

Published: Jun 6, 2024

Premiums for ACA Marketplace benchmark silver plans grew by about 5% in 2024, on average before taking into account subsidies. Meanwhile, premiums for the lowest cost unsubsidized bronze plans grew by about 6%, on average, in 2024.

Change in the Average Premium by Metal Level Before Tax Credit, 2023-2024 for a 40-year-old

However, premium changes vary by location and by metal level, with premiums decreasing in some cases. As most enrollees receive premium subsidies on the ACA Marketplaces, the net premium amount an exchange enrollee pays depends on their income and the difference in the cost between the benchmark plan (second-lowest-cost silver plan) and the premium for the plan they choose.

The map below illustrates changes in premiums for the lowest-cost bronze, silver, and gold plans by county, with and without subsidies. For data at the state-level, see our Health Insurance Marketplace tables.

2024 ACA Premium and Subsidy Changes

In 2024, 9 in 10 marketplace enrollees received premium tax credit subsidies and therefore will not necessarily pay a higher premium, even if the unsubsidized premiums in their county are rising. To account for premium increases, federal spending to finance subsidies will also increase. With the enhanced financial assistance for ACA Marketplace coverage provided by the Inflation Reduction Act, subsidized enrollees with incomes at or below 150% of poverty ($21,870 for an individual and $45,000 for a family of 4) can get a free ($0 premium) or nearly free silver plan with a very low deductible if they sign up for the lowest or second-lowest cost silver plan. Relative to the original ACA subsidies, the Inflation Reduction Act also reduced payments for middle-income enrollees and removed the upper income limit on subsidy eligibility.

Methods

We analyzed Marketplace premium data for 2023 and 2024 to determine lowest-cost premiums by metal level and benchmark premiums, as well as calculate tax credits and net premiums after tax credits for the scenarios presented. Federal Marketplace files are available through HealthCare.gov. Premiums for state-based marketplaces are from a review of insurer rate filings, state plan finders, or data provided directly by state exchanges or insurance departments. Premiums for California and Massachusetts were collected at the zip code level; premiums for Colorado, Connecticut, Maine, Minnesota, New Jersey, Nevada, New York, Virginia and Washington were collected at the county level; and premiums for Maryland and Pennsylvania were collected at the county or zip level depending on whether premiums are uniform throughout the county. For the remaining states running their own exchanges, premiums presented in this analysis were collected at the rating area level.

Because ACA subsidies only cover the “essential health benefits” (EHB) portion of the premium, enrollees with incomes between 100% to 150% of poverty may have to pay a nominal amount (e.g., $1 per month) for health coverage in counties where the lowest-cost silver plan and the second-lowest-cost silver plan include non-EHB benefits (for example, dental or vision coverage for adults or non-Hyde abortion coverage). In this analysis, we do not adjust for the non-EHB portion of premiums because that is not possible in all states with available data. Therefore, net premiums after subsidies may differ in some counties.

Calculation of the 2024 national average premium by metal level was weighted by county using 2023 plan selections obtained from the 2023 Marketplace Open Enrollment Period (OEP) County-Level Public Use File provided by CMS. In states running their own exchanges, we gathered county-level plan selection data where possible or we estimated county-level plan selections by determining the share of plan selections by county for a given state in a prior year and applying this to the total state plan selection value from the CMS 2023 OEP State-Level Public Use File.

2024 Medical Loss Ratio Rebates

Published: Jun 5, 2024

The Medical Loss Ratio (MLR) provision of the Affordable Care Act (ACA) limits the amount of premium income that insurers can keep for administration, marketing, and profits. Insurers that fail to meet the applicable MLR threshold are required to pay back excess profits or margins in the form of rebates to individuals and employers that purchased coverage.

In the individual and small group markets, insurers must spend at least 80% of their premium income on health care claims and quality improvement efforts, leaving the remaining 20% for administration, marketing expenses, and profit. The MLR threshold is higher for large group insurers, which must spend at least 85% of their premium income on health care claims and quality improvement efforts. MLR rebates are based on a 3-year average, meaning that rebates issued in 2024 will be calculated using insurers’ financial data in 2021, 2022 and 2023 and will go to people and businesses who bought health coverage in 2023.

This analysis, using preliminary data reported by insurers to state regulators and compiled by Mark Farrah Associates, finds that insurers estimate they will issue a total of about $1.1 billion in MLR rebates across all commercial markets in 2024. Since the ACA began requiring insurers to issue these rebates in 2012, a total of $11.8 billion in rebates have already been issued to individuals and employers, and this analysis suggests the 2012-2024 total will rise to about $13 billion when rebates are issued later this year.

Nearly $12 Billion in Rebates Have Been Issued So Far, with Another $1 Billion Expected in 2024

Estimated total rebates across all commercial markets in 2024 ($1.1 billion) are similar to total rebates issued in 2022 ($1.0 billion) and in 2023 ($950 million). In 2023, rebates were issued to 1.7 million people with individual coverage and 4.1 million people with employer coverage. In the individual market, the 2023 average rebate per person was $196, while the average rebates per person for the small group market and the large group market were $201 and $104, respectively (though enrollees could receive only a portion of this as rebates may be shared between the employer and employee or be used to offset premiums for the following year).

The estimated $1.1 billion in rebates to be issued later this year will be larger than those issued in most prior years but fall far short of recent record-high rebate totals of $2.5 billion issued in 2020 and $2.0 billion issued in 2021, which coincided with the onset of the pandemic.

Average Simple Loss Ratios, by Market, 2011-2023

In 2023, the average individual market simple loss ratio (meaning that there’s no adjustment for quality improvement expenses or taxes and therefore, don’t align perfectly with ACA MLR thresholds) was 84%, meaning these insurers spent an average of 84% of their premium income in the form of health claims in 2023. However, rebates issued in 2024 are based on a three-year average of insurers’ experience in 2021-2023. Consequently, even insurers with high loss ratios in 2023 may expect to owe rebates if they were highly profitable in the prior two years.

In the small and large group markets, 2023 average simple loss ratios were 84% and 88%, respectively. Only fully-insured group plans are subject to the ACA MLR rule; about two thirds of covered workers are in self-funded plans, to which the MLR threshold does not apply.

Rebate Payment Logistics

The 2024 rebate amounts in this analysis are still preliminary. Rebates or rebate notices are mailed out by the end of September and the federal government will post a summary of the total amount owed by each issuer in each state later in the year.

Insurers in the individual market may either issue rebates in the form of a check or premium credit. For people with employer coverage, the rebate may be shared between the employer and the employee depending on the way in which the employer and employee share premium costs.

If the amount of the rebate is exceptionally small (less than $5 for individual rebates and less than $20 for group rebates), insurers are not required to process the rebate, as it may not warrant the administrative burden required to do so.

Methods

This analysis is based on insurer-reported financial data from Health Coverage Portal TM, a market database maintained by Mark Farrah Associates, which includes information from the National Association of Insurance Commissioners. The Supplemental Health Care Exhibit dataset analyzed in this report does not include data from California HMOs regulated by California’s Department of Managed Health Care. All individual market figures in this analysis are for major medical insurance plans sold both on and off exchange. Simple loss ratios are calculated as the ratio of the sum of total incurred claims to the sum of health premiums earned.

Rebates for 2024 are based on preliminary estimates from insurers. In some years, final rebates are higher than expected and in other years, final rebates are lower.

Poll Finding

Public Opinion on the Future of Medicaid: Results from the KFF Medicaid Unwinding Survey and KFF Health Tracking Poll

Published: Jun 4, 2024

Medicaid is the primary program providing comprehensive coverage of health care and long-term services and supports to about 80 million low-income people in the United States. Medicaid accounts for one-sixth of health care spending (and half of spending for long-term services and support) and a large share of state budgets. Medicaid is jointly financed by states and the federal government but administered by states within broad federal rules. Because states have the flexibility to determine what populations and services to cover, how to deliver care, and how much to reimburse providers, there is significant variation across states in program spending and the share of people covered by the program.

Medicaid has been a political touchstone for the past several decades. Republican candidates often run on the promise on cutting back on federal Medicaid spending and giving states more flexibility to administer programs, while Democrats have run on expanding Medicaid coverage to reduce the number of lower-income people who are uninsured. Amidst all of this, large majorities of the public, across partisanship, continue to hold favorable views of the program and most say the current program is working well for most low-income people covered by the program.

Earlier this year, the KFF Medicaid Unwinding Survey found Medicaid enrollees1  reporting overall positive experiences with their Medicaid coverage even as some of them lost their coverage as states began unwinding their Medicaid enrollment. The latest release from KFF examines the attitudes of the public overall on the future of the Medicaid program, as well leveraging the survey of adult Medicaid enrollees, to better understand how the public’s perception of the program compares to the population who most recently was enrolled by the program.

The Public and Medicaid Enrollees Want Medicaid Financing To Stay As Is

Former President Trump said that he would not cut Social Security or Medicare if elected, but has notably not released any detailed statements on his plans for the future of Medicaid, though his budget proposals as president included plans to cap federal Medicaid spending. One way to do this is through the “block grants” – a recurring Republican proposal that would give a set amount of funding each year (usually lower than anticipated under current law) and in turn states have greater flexibility to administer program but the entitlement to coverage for enrollees and the guarantee of federal of matching dollars to states without a cap would end.

Asked which comes closer to their view of what Medicaid should look like in the future, nearly nine in ten (86%) Medicaid enrollees say “Medicaid should largely continue as it is today, with the federal government guaranteeing coverage for low-income people, setting standards for who states cover and what benefits people get, and matching state Medicaid spending as the number of people on the program goes up or down.” This is more than six times the share of enrollees (14%) who say “Medicaid should be changed so that instead of matching state Medicaid spending and setting certain requirements for health coverage, the federal government limits how much it gives states to help pay for Medicaid and states have greater flexibility to decide which groups of people to cover without federal guarantees.”

While an overwhelming majority of Medicaid enrollees prefer the program to “largely continue as it is today,” somewhat fewer adults overall – though notably still a large majority – say the same (86% vs. 71%).

Majorities of Medicaid Enrollees and the Public Overall Want Medicaid to Largely Stay as Is

Among Medicaid enrollees, majorities across gender, age, racial and ethnic groups, and partisanship agree that Medicaid should largely continue as it is today. For example, more than eight in ten Democrats and Democratic-leaning independent enrollees (89%) and Republicans and Republican-leaning independent enrollees (83%) say they want Medicaid to largely continue as it is. One in ten (11%) Democratic enrollees and one in seven (16%) of Republican enrollees would rather move to a block grant system.

While partisans among Medicaid enrollees are in consensus of keeping Medicaid as it is, the public is more divided along party lines. Among all adults, nearly nine in ten Democrats and Democratic-leaning independents say the future of Medicaid should largely continue as it is today (87%) compared to just half of Republicans or Republican-leaning independents (53%).

At Least Eight in Ten Medicaid Enrollees Want Medicaid to Remain as Is, with Overall Adults Divided by Partisanship

The Public and Medicaid Enrollees Largely Support Medicaid Expansion

Under the ACA, most states have expanded their Medicaid programs to cover nearly all adults with incomes up to 138% of poverty ($20,783 for an individual in 2024). For states that expand their Medicaid program, the federal government pays for 90 percent of the costs of this expansion with the state paying 10 percent. Under the American Rescue Plan Act states that newly adopt expansion are eligible for an additional 5 percentage point increase in the state’s traditional FMAP (federal medical assistance percentage) for two years, resulting in a temporary net fiscal benefit for these states. Several of the ten states that have not yet expanded their Medicaid programs debated expansion, but ultimately no new states adopted expansion after North Carolina implemented expansion in December 2023.

The KFF Survey of Medicaid unwinding finds that more than three in four (78%) enrollees in a non-expansion state say their state should expand Medicaid to cover more low-income uninsured people. Similarly, our recent KFF Health Tracking Poll found that a majority of adults in non-expansion states support their state expanding its Medicaid program – but to a lesser degree (66%).

Once again, among the public overall, expanding Medicaid is largely split along partisan lines, with eight in ten (83%) Democrats or Democratic-leaning independents saying they want to expand Medicaid, compared to six in ten (58%) of Republicans or Republican-leaning independents who want to keep Medicaid as it is today.

Eight in Ten Enrollees, Two-Thirds of Adults in Non-Expansion States Think Their State Should Expand Medicaid
  1. KFF interviewed 1,227 U.S. adults who had Medicaid coverage in prior to April 1, 2023 – as states began the process of determining who was still eligible for Medicaid in their state ↩︎

Global Health Policy Quiz

Published: May 31, 2024

Despite significant improvements to health throughout the world over the century, many global health challenges remain, particularly in low- and middle-income countries. The United States government has been engaged in global health activities for more than 100 years and its involvement has grown considerably over time. How much do you know about U.S. efforts to improve health around the world?

Step 1 of 10

What percentage of the U.S. federal budget is spent on global health activities?(Required)