Key Takeaways

In the wake of the COVID-19 pandemic, 90% of U.S. adults say the country is facing a mental health crisis and many reported major impacts of severe mental health problems on their families, according to a KFF/CNN survey. Additionally, drug overdose deaths sharply increased amid the pandemic and suicide deaths rose. People of color have been disproportionately affected by the rises in drug overdose and suicide deaths. People of color also are more likely to report experiences of racism and discrimination, which are associated with worse mental health and well-being. Reports of any mental illness in the past year remain lower among Hispanic, Black, and Asian adults compared to White adults. However, mental illness among people of color may be underdiagnosed due to the lack of culturally sensitive screening tools, coupled with structural barriers to care, with previous research pointing to racial disparities in receipt of mental health services.

This brief examines disparities in mental health care by race and ethnicity and other factors based on data from the 2023 KFF Racism, Discrimination and Health Survey, a large, nationally representative survey based on responses from over 6,000 adults. The survey provides unique data on access to the health care system and how factors such as racism and discrimination impact these experiences and overall health and well-being. Key findings include:

Among adults who report fair or poor mental health, White adults (50%) are more likely to say they received mental health services in the past three years compared with Black (39%) and Hispanic adults (36%). Across racial and ethnic groups, about half of all adults (53%) who report that they received mental health services said they were very or extremely helpful.

Adults identify cost concerns and scheduling difficulties as primary barriers to mental health care, and Hispanic, Black, and Asian adults disproportionately report additional challenges, such as finding a provider who can understand their background and experiences, lack of information, or stigma or embarrassment. Among adults who received or tried to receive mental health care, Asian (55%), and Black (46%) adults are more likely to report difficulty finding a provider who could understand their background and experiences compared to their White counterparts (38%). Among those who thought they needed mental health care but did not try to find a provider, Hispanic adults are more likely than White adults to say the main reason was they didn’t know how to find a provider (24% vs. 11%) and/or that they were afraid or embarrassed to seek care (30% vs. 18%).

Adults who report unfair treatment or negative experiences with a provider are twice as likely as those without these experiences to say they went without needed mental health care. Four in ten (41%) adults who report they were treated unfairly or with disrespect by a health care provider and about one-third (35%) of adults who say they’ve had at least one negative experience with a health care provider say they did not get mental health services they thought they needed compared to smaller shares of those who do not report these experiences (18% and 15%, respectively).

Reported awareness of the 9-8-8 mental health hotline remains low overall, particularly among Black, Hispanic, and Asian adults. As of Summer 2023, about one in five (18%) adults say they have heard a lot or some about 9-8-8, with Black (16%), Hispanic (11%), and Asian (13%) adults less likely to say they have heard about 9-8-8 than White adults (21%). At the same time, about one in five (21%) adults say they or a family member has ever experienced a severe mental health crisis that resulted in serious consequences such as homelessness, hospitalization, incarceration, self-harm, or suicide, with this share rising to 39% among young (ages 18-29) White adults.

Findings from the 2023 KFF Racism, Discrimination and Health Survey highlight barriers to mental health care, including costs and difficulties finding providers, with people of color citing additional challenges such as difficulty finding providers with shared background and experiences, lack of information, and stigma and embarrassment. These findings also point to areas of focus that may help address barriers to mental health care, such as diversifying the mental health care workforce and enhancing knowledge of culturally competent care among mental health care providers. Additionally, focused outreach and education efforts among specific communities may address awareness of mental health resources and stigma associated with mental health care. Findings from the 2023 KFF survey offer insight into the interactions of people of color with the mental health care system at a time when they are experiencing disproportionate increases in deaths by drug overdose and suicide and ongoing impacts of racism and discrimination.

Use of Mental Health Services

Receipt of mental health services varied across demographics and by insurance status leading up to the pandemic. As reported in KFF analyses, prior to the pandemic Black adults with moderate to severe symptoms of anxiety and/or depression were less likely than their White peers to receive mental health services. Similarly, among adults with moderate to severe symptoms of anxiety and/or depression, young adults, men, uninsured individuals, and individuals without a usual source of care were less likely than their respective counterparts to receive mental health services.

The 2023 KFF survey data show that about one quarter (23%) of adults say they have received mental health services from a doctor, counselor, or other mental health professional in the past three years. This share rises to 45% among those who report fair or poor mental health status, compared with about one in five (19%) of those who say they have good to excellent health.

Among adults who report fair or poor mental health, White adults (50%) are more likely to say they received mental health services in the past three years compared with Black (39%) and Hispanic adults (36%) (Figure 1). Additionally, among those who report fair or poor mental health status, U.S.-born adults (48%) are more likely than their immigrant counterparts (26%) to report receiving mental health services, and insured adults with fair or poor mental health status are more likely than those who are uninsured to say they received mental health services (48% vs. 27%).

About half of adults (53%) who report that they received mental health services said they were very or extremely helpful (Figure 2). The remaining 47% said they were somewhat, not too, or not at all helpful. Adults with self-reported fair or poor mental health status were less likely than those with better reported mental health status to say that the services they received were very or extremely helpful (41% vs. 59%), although this could reflect improved self-reported mental health status among those who found the services helpful.

Barriers to Accessing Mental Health Services

Prior research shows that many adults report unmet mental health needs and face barriers to accessing mental health services. Common barriers to accessing mental health care include costs, not knowing where to obtain care, limited provider options, and limited acceptance of insurance among providers. People of color face increased access barriers due to a range of factors, such as the lack of a diverse mental health care workforce, the absence of culturally informed treatment options, and stereotypes and discrimination associated with poor mental health.

Across racial and ethnic groups, about one in five adults say there was a time in the past three years when they thought they might need mental health services or medication but did not receive them. This share rises to about half (48%) among those with self-reported fair or poor mental health status, with about four in ten or more White (53%), Black (47%), and Hispanic (39%) adults who report fair or poor mental health saying they went without mental health services or medication that they thought they needed in the past three years (Figure 3).

Adults who report unfair treatment by or negative experiences with a health care provider are more likely to say they went without needed mental health care. As previously reported, Black, Hispanic, AIAN, and Asian adults report higher levels of unfair treatment when seeking health care than their White counterparts. Adults who say they were treated unfairly or with disrespect by a health care provider are more likely to report not getting mental health services they thought they needed compared to those who do not report unfair treatment (41% vs. 18%) (Figure 4), and this difference persists among those with self-reported fair or poor mental health status (67% vs. 40%). Similarly, adults who say they’ve had at least one negative experience with a health care provider, such as a provider assuming something about them without asking, suggesting they were personally to blame for a health problem, ignoring a direct request or question, or refusing to prescribe pain medication they thought they needed are more likely to report not getting mental health services they thought they needed compared to adults who did not report a negative experience (35%. vs 15%). This difference also persists among those with self-reported fair or poor mental health status (56% vs. 37%).

Among adults who say they needed but went without mental health services, about half (48%) say they tried to find a mental health care provider, while the remaining half (52%) say they did not. Additionally, seven in ten parents with children who they thought might need mental health services or medication but went without them in the past three years (or 14% of all parents) say they tried to find a provider for their child.

Adults who received or tried to find a mental health care provider for themselves or their children identified scheduling delays, difficulty finding a provider who could understand their background and experiences, and concerns about affordability or coverage as challenges. Overall, 32% of adults received mental health services or tried to find a mental health care provider for themselves or their children in the past three years. Among these adults, about four in ten say that it was very or somewhat difficult to find a mental health care provider who could treat them in a timely manner (44%), understand and relate to their background and experiences (41%), or who they could afford (41%), and 36% say it was very or somewhat difficult to find one who would take their insurance. Compared to their White counterparts (38%), Asian (55%), and Black (46%) adults are more likely to report difficulty finding a provider who could understand their background and experiences (Figure 5).

Concerns about costs and scheduling difficulties are primary reasons cited for not trying to find a mental health care provider among those who say they needed mental health care. A total of 12% of adults thought they or their children needed mental health services in the past three years but report they did not try to find a provider. Among these adults, the main reasons they say they did not try to find a provider were because they thought it would be too expensive (37%), they were too busy or could not take the time off (31%), or they didn’t think it would help (29%). Somewhat smaller shares say they were afraid or embarrassed to seek care (21%), did not know how to find a provider (15%), or did not think they could find a provider with a shared background or experiences (14%) (Figure 6). Hispanic adults who thought they or their children needed mental health services but did not try to find a provider are more likely than their White peers to say the main reason was because they didn’t know how to find a provider (24% vs. 11%) or that they were afraid or embarrassed to seek care (30% vs. 18%). Black adults who thought they or their children needed mental health services but did not try to find a provider are more likely than their White peers to say the main reason was because they didn’t think they would find one who shared their background and experiences (21% vs. 10%).

Mental Health Crises and Awareness of 9-8-8 Mental Health Hotline

Since the launch of the federally mandated crisis number, 9-8-8, awareness remains low overall, particularly among Black, Hispanic, and Asian adults. In July 2022, 9-8-8 became available to all landline and cell phone users, providing a single three-digit number to access a network of over 200 local and state funded crisis centers where those in need may receive crisis counseling, resources and referrals. While national answer rates increased alongside increases in call volume after the implementation of 9-8-8, awareness of the hotline remains low overall. As of Summer 2023, about one in five (18%) adults say they have heard a lot or some about 9-8-8, with Black (16%), Hispanic (11%), and Asian (13%) adults less likely to say they have heard about 9-8-8 than White adults (21%) (Figure 7). Immigrant adults and adults with limited English proficiency also are less likely to say they have heard about 9-8-8 compared to those who are U.S.-born and English proficient.

Low awareness of the 9-8-8 hotline comes at a time when about one in five adults (21%) say they or a family member ever experienced a severe mental health crisis that resulted in serious consequences such as homelessness, hospitalization, incarceration, self-harm, or suicide (Figure 8). White adults (24%) are more likely to report having had or having a family member who has had a severe mental health crisis compared to Asian (9%), Hispanic (16%), and Black adults (18%), a difference that is largely driven by higher rates among White adults who are younger and have lower incomes. Younger adults (ages 18-29) are more likely to say they or a family member who experienced a severe mental crisis resulted in one of these consequences across racial and ethnic groups, with this share rising to about four in ten young White adults (39%). Similarly, among lower income adults ($40,000 annually or less), about a third (34%) of White adults report this experience compared with lower shares of Hispanic (18%), Black (19%), and Asian (11%) adults.

Alcohol use disorder (AUD) is often an underrecognized substance use disorder (SUD) despite its substantial consequences. Over half of US adults (54%) say that someone in their family has struggled with an alcohol use disorder, making it the most prevalent non-tobacco substance use disorder. Yet, only one-third of adults view alcohol addiction as a crisis, compared to over half who see opioids as such. Federal data show that 1 in 10 people had an alcohol use disorder in the past year, over 4 in 10 alcohol users report binge drinking in the past month, and per capita alcohol consumption is higher than the decade prior. Treatment rates for alcohol use disorders are notably low, especially for the use of medication, a recommended AUD treatment component. Although the opioid crisis has been declared a public health emergency by the U.S. Department of Health and Human Services since 2017, no similar declaration exists regarding alcohol deaths. However, HHS has set a priority goal of reducing emergency department visits for acute alcohol use, mental health conditions, suicide attempts, and drug overdoses by 10% by 2025.

This analysis focuses on the narrowest definition of alcohol deaths known as “alcohol-induced deaths” (referred to as “alcohol deaths” throughout the brief). These alcohol deaths are caused by conditions directly attributable to alcohol consumption, such as alcohol-associated liver diseases. Broader definitions of alcohol deaths extend this definition to also encompass cases where an alcohol-induced condition was a contributing factor, but not the underlying cause of death. Key takeaways from this analysis of CDC WONDER data from 2012 to 2022 include the following:

• Alcohol deaths increased steadily over the past decade with sharp rises during the pandemic years. Overall, the national alcohol death rate has risen 70% in the past decade, accounting for 51,191 deaths in 2022, up from 27,762 deaths in 2012.
• Alcohol deaths in 2022 were highest among people aged 45 to 64, American Indian and Alaska Native (AIAN) people, and males. Alcohol death rates for AIAN people are the highest–5 times higher than death rates for White people, the racial group with the next highest prevalence. Deaths are rising fastest among adults aged 26 to 44, AIAN people, and females–with these groups experiencing nearly or more than a 100% rise in alcohol mortality rates in the last decade.
• Rates of alcohol deaths varied considerably across states in 2022. While all states and D.C. experienced increases in deaths rates over the past decade and during the pandemic, the rate of change varied by state and year, with some states’ death rates rising most sharply during the pandemic and other state experiencing rises more evenly before and during the pandemic. Rural areas have a higher rate of alcohol deaths and experienced greater growth in death rates both over the past decade.
• The number of alcohol-related deaths rises to 105,308 under a broader definition that counts deaths where alcohol-induced conditions are either the underlying cause or a contributing factor. This exceeds the numbers for opioid and suicide deaths, which also use this broader definition, totaling 83,437 and 49,594, respectively. 

What are the trends in alcohol deaths?

Alcohol deaths have steadily climbed over the past decade, a trend that accelerated during the pandemic (Figure 1). When adjusted for population growth and age, the alcohol death rate has risen by 70% from 2012 to 2022, moving from 7.97 to 13.53 deaths per 100,000 people. Although deaths fell somewhat in 2022, they remain far higher than a decade ago. From 2012 to 2019, the year over year rise in deaths rates averaged about 4% per year, and then jumped during early pandemic years, with the biggest rise from 2019 to 2020. Other data mirror this trend – emergency department (ED) visits for SUD are on the rise and account for twice the number of ED visits compared to opioids. Alcohol related ED visits account for nearly half of all SUD related visits (45%), far higher than the next highest group, opioids, accounting for 13% of ED visits.

How do alcohol death rates vary and how have they changed across demographics groups?

Alcohol deaths in 2022 were highest among people aged 45 to 64, males, people living in rural areas, and AIAN people. Alcohol death rates for AIAN people are by far the highest–5 times higher than death rates for White people, the racial group with the next highest prevalence. Across age groups, people aged 45 to 64 have the highest alcohol death rate, followed by 65+. Death rates in males are more than double that of females and people who reside in rural areas have death rates higher than those who live in urban areas (Figure 2).

Over the past decade (2012-2022), alcohol death rates grew fastest among people 26 to 44, AIAN people, and females (Figure 3). Overall alcohol consumption has risen somewhat in recent years, but increases may have been concentrated among certain populations as well as other risk factors.

• People aged 26 to 44. Individuals aged 26 to 44 experienced the fastest increase in alcohol death rates, with a rise of 144% over the past decade and over 50% during the pandemic. While this younger age group showed the steepest rate of increase, the largest overall growth in the number of deaths occurred among those aged 45 to 64. This somewhat older group already had the highest death rates and experienced the largest increase in death rates (12 additional deaths/100,000) in the past decade, more than any other group.
• AIAN people. Alcohol deaths for AIAN people have nearly doubled in the last 10 years. During the pandemic years, alcohol death rates increased by almost 25 deaths per 100,000 AIAN people. Increases in alcohol deaths among AIAN people follows worsening trends in other areas related to behavioral health, where AIAN have both the highest rate and fastest growing suicide and overall drug overdose death rates.
• Females. Although males die of alcohol causes more often than females, the relative growth was faster for females over the past 10 years, increasing by 86% for females compared to 61% for males. Heavier drinking may impact women more quickly than men, which may result in the faster development of serious health consequences that contribute to death.

How do alcohol death rates vary and how have they changed across geography?

In 2022 there was wide variation in alcohol death rates. In 2022, New Mexico’s death rate was the highest at 42.7 per 100,000 people, which was more than six times higher than Hawaii, the state with the lowest rate at 7.1 per 100,000 people (Figure 4).

While all states experienced an increase in alcohol deaths, those rates varied widely.  Nationally, alcohol death rates increased by 70% over the past decade, including a 30% rise during the pandemic years alone (2019-2022). However, the extent of these increases varied substantially across states. For instance, the District of Columbia saw a relatively low increase of 24% over the decade, whereas Connecticut experienced a much larger rise of 167%. During the pandemic, increases ranged from 9% in Wyoming and New Jersey to 86% in Mississippi. Some states, like Vermont, had most of their rises in alcohol death rates before the pandemic, with only 12% of the growth occurring during pandemic years. In contrast, Mississippi’s rates more than doubled over the past decade, and over half of that increase happened during pandemic years. Many factors may contribute to the differences in alcohol mortality rates across states, some of which may include differences in alcohol consumption and cultural attitudes, state-specific alcohol policies, and treatment rates (Figure 4).

Rural areas experienced faster growth in alcohol deaths than urban areas, driven by sharp rises during the pandemic. Deaths grew across both rural and urban areas in the past decade; however growth was fastest in rural areas–nearly doubling in the past decade and increasing by 35% during pandemic years. Existing shortages of mental health and substance use treatment professionals may make it particularly difficult to access care in rural areas, where the supply of behavioral health workforce is even more scarce. During the pandemic, telehealth services for behavioral health and other care may have been more accessible to those living in urban areas, where an internet connection is more likely to be available or reliable (Figure 5).

What factors may contribute to the increases in alcohol deaths in the past 10 years?

Alcohol contributes to more deaths than opioids and suicides when the alcohol conditions that contribute to death are included. Defining alcohol deaths can be complex due to the gradual onset of many conditions caused by or linked to alcohol and its ability to exacerbate or increase the risk of developing other health conditions. This analysis adopts the strictest definition of alcohol deaths, focusing on deaths that were directly caused by conditions directly due to alcohol, such as alcohol-related liver diseases. However, if deaths where alcohol conditions are a contributing factor listed on the death certificate —termed ‘alcohol-related deaths’—are included, the number of deaths increases to 105,308 in 2022, though some cases may overlap. This exceeds the numbers for opioid and suicide deaths, which also use this broader definition, totaling 83,437 and 49,594, respectively. Unlike the immediate effects of opioid overdoses or suicides, alcohol-related conditions often develop slowly over many years. These conditions can directly cause death or worsen other illness. For instance, it may take many years of heavy drinking before alcohol-associated liver diseases, the most common cause of alcohol deaths, to develop. This slower disease progression as well as the role of alcohol in exacerbating other conditions may contribute to the higher number of deaths counted under the expanded definition. The number of alcohol deaths rise even more when the criteria are broadened to include alcohol’s role in increasing the risk of death by other conditions or events, such as cancer or car accidents involving alcohol (Figure 6).

Rises in alcohol deaths may be attributed to a variety of factors including, in part, increases in drinking and low treatment rates. Alcohol consumption and some indicators of binge drinking have been on the rise in recent years, particularly among some demographic groups. Excessive alcohol consumption is tied to the development of alcohol-related diseases, which can be fatal. A variety of factors may have contributed to increases in drinking including a growing social acceptability of alcohol and loosening of alcohol policies at a state level. Other factors, such as increased stressors due to the pandemic and other issues may have increased drinking behaviors.

Treatment rates for alcohol use disorder are very low. Federal survey data show that in 2022, only 7.6% of people (12+) with a past year alcohol use disorder received any treatment. Although medications for alcohol use disorder have been shown to reduce or stop drinking, uptake of these medications is extremely low; with only 2.1% of people who meet criteria for an alcohol use disorder (diagnosed or not) receive medication treatment. Treatment rates are slightly higher among those who do receive a diagnosis–for instance, 10% of Medicaid enrollees diagnosed with an alcohol use disorder received medication, 34% received counseling services, and 74% received some type of interaction with a treatment, such as therapy, medication, assessment, or supportive service.

Barriers to alcohol use disorder treatment include a combination of provider, patient, financial, and infrastructure factors. Providers often lack confidence or knowledge in treating alcohol use disorder and are uncomfortable with medication and other treatment options, which may decrease the likelihood that they will manage treatment or make referrals. To address this, recent initiatives are enhancing education for both practicing and training providers through mandatory training programs and curriculum enhancements in medical schools. Further, recent changes to SUD confidentiality regulations are expected to simplify the diagnosis and coordination of care for individuals with substance use disorders (SUD). Insufficient treatment infrastructure or a shortage of a skilled workforce to staff facilities and deliver care can also play a role in treatment rates.

From the patient perspective, limited understanding of what constitutes problematic drinking and attitudes towards seeking treatment can hinder recognition of the need for help. For example, among those who meet the criteria for SUD—which may include symptoms like increased tolerance, repeated attempts to quit or control use, or social problems related to use–95% of adults did not seek treatment and didn’t think they needed it. Initiatives aimed at early screening in non-traditional settings, such as schools may help early detection and lead to more timely linkages of individuals to treatment resources. When people think they might need treatment, practical issues such as insurer coverage of services, locating a provider that will accept the patient’s insurance, availability of time off from work, childcare, and the affordability of treatment/out of pocket costs can also influence decisions about seeking or staying in treatment.

988, the federally-mandated suicide and crisis line, supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), includes specific services to meet the needs of LGBTQ youth and young adults. Given that LGBTQ people face substantial experiences of stigma and discrimination, more pervasive mental health challenges, and greater unmet need for mental health services, a dedicated 988 service provides a targeted intervention for this community.

LGBT adults are more likely than non-LGBT adults to describe their mental health and emotional well-being as either “fair” or “poor” (39% v. 16%) and more likely to report being always or often anxious, depressed, or lonely over the past 12 months. Especially concerning is that, in 2021, 45% of LGBTQ high school students reported having seriously considered suicide during the past year. However, despite greater need, LGBT people are more likely to report going without a needed mental health services than non-LGBT people. Further, about two-thirds (65%) of LGBT adults say they have experienced at least one form of discrimination in their daily life at least a few times in the past year compared 40% of non-LGBT adults and experiences of stigma and discrimination contribute to mental health challenges. In addition, it has been well documented that anti-LGBTQ policy environments can negatively impact the community’s well-being and debates over LGBTQ rights are currently playing out in the courts as well as on the political stage.

This analysis examines performance metrics to assess utilization of 988’s LGBTQ service (which SAMHSA refers to as the LGBTQI+ subnetwork), compared to 988’s general service usage, from December 2023 to March 2024 (the most current and comprehensive data available). The LGBTQ pilot first launched in September 2022, but LGBTQ specific metrics did not become available to the public until December 2023.

Key takeaways include:

• During the four-month period, 10% of all 988 contacts, including 19% of all texts, were made via 988’s LGBTQ service. Users can contact 988 via call, chat, or text.
• A plurality of contacts to 988 came via calls for both the LGBTQ service and the general 988 service, but those using the LGBTQ service were about twice as likely to use text.
• Those using the LGBTQ service were more likely to encounter certain challenges with the service compared to those using the general 988 service. These include double the call abandonment rate (21% v. 11%) and substantially longer call wait times (with monthly averages about double that of the general line).

What is the LGBTQ 988 service and how does it work?

A pilot for a 988 service to address the specific needs of LGBTQ young people was launched shortly after the main 988 line and later expanded to a full-time service. Recognizing the growing need for mental health crisis services in the U.S., the federal government made the mandated Suicide & Crisis Lifeline 988, supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), available to all landline and cell phone users in July 2022, providing for the first time, a single three-digit number to access a network of over 200 local and state-funded crisis centers. In addition, in September 2022, 988 launched a pilot to specially address the needs of LGBTQ young people (those under 25) by offering text, phone and chat services “with a counselor trained explicitly to support LGBTQ+ youth and young adults,” but the service had limited hours. In March 2023, that pilot was expanded to run 24/7 across all modalities. (KFF provided additional history of the 988 line in an earlier brief.)

Operation of the LGBTQ line differs from the main 988 line in that services are provided through specific centers with specialty LGBTQ training rather than local crisis centers located across the country. Originally, the pilot started with one contractor (Trevor Project), but has since evolved to include seven centers (prior to the expansion, there were media reports of capacity issues and other challenges). When contacts cannot be answered by LGBTQ specific operators, they are diverted to the main 988 lines, though data on how often this occurs are not available.

What do we know about awareness and utilization of the LGBTQ 988 service?

As a relatively new service, lack of awareness of the availability of the 988 hotline may be a barrier. Recent survey data from KFF indicate that most (8 in 10) LGBT adults have heard little to nothing about the resource, similar to the share among non-LGBT adults. This low awareness is similar among young LGBTQ adults (18-29), with about 8 in 10 (78%) reporting limited or no knowledge of the 988 hotline, despite there being a service focused on supporting LGBTQ individuals under 25.

Additionally, LGBT adults report more difficulty with the standard police response to a mental health crisis call. LGBT adults are more likely than non-LGBT adults (54% v 26%) to think that that calling 911 in a mental health crisis would do more to hurt the situation than help. Given this backdrop, access to culturally competent mental health services for LGBTQ people may be particularly impactful and targeted efforts may help to increase awareness and use.

Over a recent four-month period, 10% of all 988 contacts, including 19% of texts, were made via 988’s LGBTQ service (Figure 2). This is higher than the distribution of LGBT people in the population as a whole (7%). Since younger people are more likely to identify as LGBTQ, including 20% of Generation-Z, it could help to explain the relatively high rates of LGBTQ service use, especially given the service’s focus on younger people. Greater prevalence of mental health conditions and experiences of stigma and discrimination among LGBTQ people, may also, help explain high use of the 988’s specialty service.

Traffic to the LGBTQ service averaged 46,998 contacts per month over the period and increased from 45,703 contacts in December 2023 to 51,535 contacts in March 2024 (13%). Traffic increased for the service overall as well, albeit at a slightly slower pace (an 8% increase). Across the four-month period,187,991 individual contacts were made to 988’s LGBTQ service via calls, chat, and text. 1.8 million general service contacts were made to 988.

A plurality of contacts to 988 came via calls, for both the LGBTQ and the 988 service overall, but those using the LGBTQ service were about twice as likely to use text and less likely to use calls (Figure 3). Nearly one-third (31%) of LGBTQ service users contacted 988 via text, compared to fewer than one-in-five service users overall (17%). While it was the most common contact modality for both groups, LGBTQ users were less likely to connect to 988 via call (58% v 70%) than general service users. The use of chat was similar for both groups (11% v 12%). In addition to promoting the service overall to improve awareness, given LGBTQ youth and young adult’s wider preference for text, promoting this modality, along with the call line, may be especially useful in servicing the needs of this population.

Callers to the LGBTQ phone line, however, faced higher call abandonment rates than callers to non-LGBTQ lines (Figure 4). The average abandonment rates for LGBTQ line callers were nearly double the rate of general line callers (21% v. 11%) (Figure 4). SAMHSA uses the term “abandoned” to describe when the person seeking 988 services hears/sees the initial 988 greeting, but is disconnected before engaging with a counselor. Per SAMHSA, this may occur due a technical reason (e.g. internet or mobile connection strength or service interruptions, etc.) or because the person seeking assistance ends the contact before a counselor answer which could also happen for a range of reasons, such as they had to wait too long or decided they were not comfortable discussing their experience. Since LGBTQ people in a mental health crisis may also fear discussing their sexual orientation or gender identity, they may be quicker to change their minds about seeking help and a prompt pick-up may improve call completion. Regardless of the reason for call abandonment, there may be opportunities to improve call experiences for users of the LGTBQ line which are nearly double the wait time of general 988 line. LGBTQ service users had lower abandonment rates for chat and the same abandonment rates for text compared to general line users.

In addition, wait time for the LGBTQ phone line was substantially longer than for 988 calls overall—with monthly averages about double that for the general line (Table 1)—which may contribute to the higher abandonment rates. The average monthly wait time for calls to the LGBTQ line were close to a minute whereas they were about 30 seconds for the general 988 service. In contrast, for other contact methods, average text and chat, wait times were shorter for LGBTQ users compared to general 988 users. While, higher than general line users, the wait times for LGBTQ callers face today may actually represent an improvement from the initial launch period of the service when media reports suggested significant challenges with wait times.

Introduction

The Supreme Court’s Dobbs ruling has heightened interest in affirming the right to contraception. While the Court’s majority opinion stated that the Dobbs decision does not “cast doubt on precedents that do not concern abortion,” Justice Thomas argued in his concurring opinion that in future cases, the Court should reconsider precedent that relied on the same principles as Roe – including Griswold v. Connecticut, the Court’s 1965 landmark decision that recognized the right of married people to obtain contraceptives – and overturn those decisions. The prospect of the Court overturning Griswold moved some in Congress to introduce federal legislation that would protect the right to contraception, though that legislation is unlikely to advance in the current divided Congress. Similarly, some state legislators have recently introduced measures to protect the right to obtain contraceptives.

However, even with the current constitutional protections of Griswold in place, uncertainty has emerged around people’s ability to access certain contraceptive methods, such as IUDs and emergency contraceptive pills (often confused with medication abortion), which are erroneously believed by many to be abortifacients. If, as the Supreme Court’s majority indicated, the basis for their reasoning hinges on whether “potential life” is involved in a law, the conflation of contraception with abortifacients could be the reasoning in a future case or in the application of certain laws. Since the Dobbs decision in 2022, a growing number of states have passed laws or constitutional amendments to secure the right to contraception for their residents. Recently, former president Donald Trump said that he believes the right to contraception should be up to the states, a statement he followed up with a social media posting saying that he would not limit contraception. With several state ballot initiatives on the path to be facing the voters November 2024 and the former president’s statement on contraception, this issue is likely to emerge as an election issue this fall. Senate Majority Leader Schumer also recently stated his intention to take a vote to the Senate floor on a bill that would protect contraceptive access nationally. This issue brief explains how misinformation about contraceptives and how pregnancy is defined in state abortion bans may impact contraceptive access, and outlines the legal protections some states have established to affirm the right to obtain contraceptives.

Background

Supreme Court Decisions Recognizing the Right to Contraception

Currently, the right to contraception is protected by two landmark Supreme Court decisions, Griswold v. Connecticut (1965) and Eisenstadt v. Baird (1972). In Griswold, the Court recognized that the constitutional right to privacy encompasses the right of married people to obtain contraceptives. Prior to the Griswold decision, many states outlawed contraceptives, prohibiting clinicians from prescribing, or even discussing, contraceptive methods with their patients. After the Griswold decision, some states continued to have these prohibitions for single people, only allowing married women to obtain contraceptives. These laws spurred the litigation that resulted in the High Court’s decision in Eisenstadt, where the Court extended the constitutional protections of Griswold to unmarried people.

Misconceptions about Emergency Contraceptives (EC) and IUDs

Although intrauterine devices (IUDs) and emergency contraceptives (EC) – such as Plan B, Ella, and the emergency application of IUDs – work by preventing pregnancy, many people mistakenly believe they are abortifacients and can end a pregnancy. Polls indicate that as many as 73% of people incorrectly think emergency contraceptive pills can end a pregnancy in its early stages. Additionally, some people wrongly believe that IUDs work primarily by preventing implantation of a fertilized egg on the uterine lining.  However, research has shown that these contraceptive methods work by inhibiting ovulation or by making it harder for sperm to reach an egg. Despite some common misconceptions, emergency contraceptive methods and regular use of the IUD do not terminate a pregnancy, stop the implantation of a fertilized egg, or affect a developing embryo.

Some Abortion Bans May be Interpreted to Limit Contraceptive Access

The definitions that abortion bans in some states employ, coupled with the misunderstanding that certain contraceptives are abortifacients, may be used to limit access to contraceptives. While leading medical organizations define pregnancy to begin at the implantation of a fertilized egg, a number of abortion bans define pregnancy to begin at fertilization and “fetus” and “unborn children” as living humans from fertilization until birth. The total abortion ban in Tennessee, for instance, defines pregnancy as the “reproductive condition of having a living unborn child within [the pregnant person’s] body throughout the entire embryonic and fetal stages of the unborn child from fertilization until birth.” If abortion bans establish that a pregnancy exists from the moment of fertilization, preventing the implantation of a fertilized egg could be construed as terminating a pregnancy. This kind of definition could potentially be used to ban or restrict contraceptive methods that people incorrectly believe to end a pregnancy.

For example, Missouri defines abortion to outlaw “[the] termination of the pregnancy of a mother by using or prescribing any instrument, device, medicine, drug, or other means or substance with an intention other than to increase the probability of a live birth or to remove a dead unborn child”. The ban additionally defines “unborn child” as “the offspring of human beings from the moment of conception” — which they define as fertilization — “until birth.”  The ban does not provide a definition for pregnancy, but instead establishes personhood for fertilized eggs, which could be interpreted as banning anything that prevents the implantation of a fertilized egg on the uterine lining, a possibility the state’s governor did not firmly deny in the immediate aftermath of the Dobbs decision. As a result, when the state’s abortion ban went into effect, a major hospital system in Missouri immediately stopped providing Plan B – an emergency contraceptive – out of fear of charges that could have resulted from a prosecutor’s misunderstanding of how Plan B works. The hospital system resumed providing the emergency contraceptive after the Attorney General’s office and the governor clarified that the ban did not affect Plan B. However, this situation demonstrates how the definitions included in abortion bans, which imply pregnancy starts at fertilization, coupled with misunderstandings of how contraceptives work, could limit access to the full range of contraceptive methods.

Currently, most other abortion bans that define pregnancy to begin at fertilization also limit the definition of abortion to providing procedures or medication to people “known to be pregnant” or with “clinically diagnosable pregnancies”. This definition of abortion would preclude these bans from being used to limit contraceptives. This is because contraceptives – emergency or otherwise – do not end an existing pregnancy and emergency contraceptives are only effective up to 5 days after intercourse, while the earliest a pregnancy can be clinically confirmed is approximately 10 to 11 days after fertilization. Even with a misunderstanding of how contraceptives work, these bans do not affect conduct prior to the time when a pregnancy can be confirmed. Additionally, the abortion bans in a few states explicitly clarify that they do not prevent the prescription, sale, or transfer of birth control devices and oral contraceptives.

Notably this issue came up in the 2023 race for Kentucky Governor. In a questionnaire from a state anti-abortion organization, one Republican contender indicated his support for fetal personhood, and prohibiting public funds for abortion with a definition that included contraceptive methods such as the “morning after pill,” Norplant, Depo Provera and the so-called “standard birth control pill.”  While the definition was provided by the anti-abortion organization, not the candidate, it illustrates the lack of understanding of contraceptive mechanisms of action and fails to distinguish between a drug or device that prevents pregnancy and those that are used to terminate a pregnancy.

State Protections for the Right to Contraception

Fourteen states – California, Colorado, Florida, Illinois, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, Ohio, Oregon, Rhode Island, Vermont, and Washington – and D.C. currently have legal or constitutional protections for the right to contraception. In six states and D.C., these protections were enacted since the Supreme Court’s decision in Dobbs in June 2022 as a legislative and citizen response to the fall of Roe.  In California, Michigan, and Vermont, voters passed constitutional amendments through ballot measures in the November 2022 election recognizing a broad right to reproductive autonomy, which includes the right to use or refuse contraceptives. In these states, the right to reproductive autonomy also includes the right to abortion and sterilization. In addition to the three states that had constitutional amendments in the November 2022 ballot, the legislatures in D.C., Minnesota, and New Mexico have enacted laws protecting contraception since June 2022. And in 2023, Ohio voters approved Proposition 1, amending their state constitution to protect reproductive decisions, including those regarding contraception and abortion.

Although a number of the protections for contraception were enacted post-Dobbs, more than half of the states that have such protections instituted them before June 2022. Most of these laws – including those in Colorado, Illinois, Massachusetts, New Jersey, Rhode Island, and Vermont – were passed in the years leading up to the fall of Roe. Of the states that currently protect the right to contraception, all but three enacted these protections after 2019. The states of Oregon, Washington, and Florida had enacted their laws protecting contraceptives in 2007, 1991, and 1972, respectively.

Most laws protecting the right to contraception also protect a broader set of reproductive health care decisions, such as miscarriage management, maternity care, and assisted reproduction. Some states, such as Florida and Oregon, however, have more specific laws protecting the right to contraception. Oregon has separate protections for emergency contraception, voluntary sterilization, and termination of pregnancy. In fact, Florida is the only state with a statutory right to contraception that also has passed abortion bans, with a 6-week LMP ban in effect.

Much like any other legal protection, enshrining these rights in the state constitution creates stronger and more stable protection than simply enacting laws, which can be repealed with a change in party control of the state legislature or Governor. In contrast, a constitutional amendment that explicitly protects the right to contraception, or reproductive autonomy more broadly, is harder to change or repeal.

Proposed State Bills and Constitutional Amendments

Legislators in several states have introduced bills and proposed constitutional amendment ballot measures to protect the right to contraception since the Dobbs decision. Legislators in Hawai’i, Maryland, Nevada, and Washington, among other states, have proposed constitutional amendments to create protections for contraception. Most of these measures are in committee or awaiting a vote with the legislature, but the Maryland and Nevada measures have passed. Maryland’s proposed constitutional amendment will be on the November 2024 ballot. In Nevada, constitutional measures must pass twice in the legislature before they are placed on a ballot and the earliest it may be listed on the ballot is November 2026. Further, lawmakers in several states, including Arizona, Iowa, and Virginia, have introduced bills protecting the right to contraception during the 2023 and 2024 legislative session. None of these bills passed during the 2023 legislative session. The Virginia bill introduced during the 2024 session has passed both chambers, but it was vetoed by the governor.

Federal Response

At the federal level, the Right to Contraception Act – a bill that would have protected the right to obtain and use contraceptives – and the Access to Safe Contraception Act – which would prevent states from banning the prescription, provision, or use of FDA-approved contraceptives – were introduced in the House and the Senate in the weeks after the Supreme Court issued the Dobbs decision. Shortly after the bill was introduced, the then Democrat-led House passed the Right to Contraception Act, but it did not receive a vote in the Senate due to a lack of the necessary votes needed to end a filibuster. The Right to Contraception Act was reintroduced in the current Congressional session in June 2023, but it does not have sufficient support to pass in the House or end the filibuster in the Senate at this time. Senate Majority Leader Charles Schumer has announced his intention to fast-track a Senate floor vote that would codify the right to contraception that was granted in the Griswold case assuring that this will be raised by Democrats as an election issue.

In the months following the Dobbs decision, President Biden issued two executive orders aiming to protect access to reproductive health care services, including contraceptives.  While the executive orders do not specifically address the “right” to contraception, they call on federal agencies and regulators to assure that access to contraceptive services and supplies is broad and unimpeded by barriers related to costs, coverage, availability, and other factors. For example, in July 2022, under the directive of one of these executive orders, the U.S. Department of Health and Human Services issued guidance reminding retail pharmacies of their obligations under federal civil rights law. Specifically, the guidance pointed out that “if [a] pharmacy otherwise provides contraceptives (e.g., external and internal condoms) but refuses to fill a certain type of contraceptive because it may prevent pregnancy, the pharmacy may be discriminating on the basis of sex.”

Recent KFF polling suggests that 21% of adults consider the right to contraception to be a threatened right, rising to over one-third of Democrats. One in four Democratic women feel that the right to contraception is under threat, but concern is lower among Republican women (8%). Notably, many are not sure whether it is a secure right, but that may change as the issue gets additional attention in the upcoming election.

In 45 states, fewer than half of nursing facilities currently meet all three staffing minimums required in the final federal rule that the Centers for Medicare and Medicaid Services (CMS) released in April, and in 28 states, less than a quarter do, according to a new KFF analysis. The share of facilities that meet these requirements ranges from 5% or lower in four states (AR, TN, TX and LA) to 50% or higher in five states (AK, ND, ME, HI and OR) and DC.In rural areas, 20% of nursing facilities currently meet these standards, compared to 18% in urban areas. Despite having similar starting points, nursing facilities in urban areas have two fewer years to comply with all provisions of the rule, facing a deadline of May 2027 compared to May 2029 in rural areas. Though they face different challenges, urban and rural facilities currently have similar staffing patterns and both face potential staffing shortages. Rural facilities may struggle to find staff because there are fewer available workers, while urban facilities may struggle because available workers have more job options.  

Across the U.S., only 1 in 5 (19%) nursing facilities currently meet all three staffing minimums. The share that comply is even lower among for-profit facilities (only 11%), compared to 41% of non-profit facilities and 39% of government facilities. When the new federal requirements are fully implemented, nursing facilities will be required to maintain at least 0.55 registered nurse and 2.45 nurse aide hours per resident day (HPRD) in addition to the overall 3.48 HPRD requirement. Nursing facilities may apply for exemptions from these minimum staffing requirements if they are located in an area with workforce shortages. The nursing home industry has identified the cost of hiring and retaining sufficient staff as a major concern, while resident and family advocates have long said new requirements are necessary to address well-documented issues with the quality of patient care.

Forthcoming decisions about how CMS will enforce the new staffing requirements and the ease by which facilities can acquire hardship exemptions may impact the effectiveness of the federal rule as well as how much costs could rise.

There is an ongoing multi-state outbreak of H5N1 influenza virus in dairy cattle and other animals in the U.S., the first time this virus is known to have infected cows. So far, only one human case of H5N1 has been associated with the U.S. cattle outbreak, an eye infection in a worker at a dairy farm in Texas. However, there is increasing concern that farmworkers are being exposed to the virus and additional human infections may be occurring. Moreover, repeated exposures between infected animals and humans could result in the virus becoming more transmissible in humans, even potentially sparking a new influenza pandemic.

Dairy farm workers are the population most directly exposed to H5N1 infected cattle, and therefore the people at highest risk of further infections. They also face other occupational health risks such as injury and musculoskeletal injuries. However, reports suggest there are multiple challenges to providing testing and other health services to this population including lack of health coverage, language barriers, and fears or concerns about engaging with health officials.

In general, there is limited information available about the number of dairy farm workers and the working conditions, demographics and insurance status of those workers, especially at the state level. Estimates suggest that as of 2018, there were roughly 130,000 employees on U.S. dairy farms, a subset of whom come into direct contact with cattle and would be at risk for exposure. Previous studies indicate dairy farm workers typically receive poor health and safety training and often lack personal protective equipment. A USDA study found that, in 2015, over 40% of dairy farmer household members were uninsured, the highest rate among farm households nationwide, and a 2014 survey conducted for the National Milk Producers Federation estimated that immigrant workers make up over half of the dairy labor force. A 2020 survey of dairy farms nationwide found over half of farms report having employees who have a first language other than English. However, these surveys may not be representative of dairy farms and farmworkers nationwide. For example, compared to dairy farms nationwide, dairy farm respondents to the 2020 survey were disproportionately in the Northeast and had larger herd sizes, which is associated with greater likelihood of hiring non-family labor and may affect the reported characteristics of workers.

To provide more information about workers at potential risk for the H5N1 influenza outbreak we analyze demographic characteristics, income, and health coverage for “animal production and aquaculture” workers in the U.S. and in states experiencing outbreaks using data from the 2022 American Community Survey (see Methods below). “Animal production and aquaculture workers” include workers who are “primarily engaged in keeping, grazing, breeding, or feeding animals.” This category includes dairy farm workers as well as other animal production workers but is the most specific category with data available to examine these workers’ characteristics. Data do not allow for estimates of what share of these workers are dairy farm workers. We compare the characteristics of workers in the animal production worker category with all workers in the U.S., and within affected states. However, of the nine states with reported dairy cattle infections as of May 14, 2024, two (Idaho and New Mexico) are not included in the state-level analysis due to insufficient sample sizes.

Findings

Animal production workers are more likely than workers overall to be Hispanic and noncitizen immigrants as well as to be uninsured, have lower household incomes (less than $40,000 per year), and have limited English proficiency (LEP) (Figure 1). Overall, about one in five animal production workers is Hispanic, slightly higher than the share of U.S. workers overall (22% vs. 19%). Animal production workers also include a higher share of noncitizen immigrants compared to workers overall (13% vs 8%). One in five (20%) animal production workers are uninsured, about twice the share of workers overall (9%), which may, in part, reflect that they have lower incomes (18% vs. 12%). They also are more likely to have limited English proficiency (16% vs. 9%).

These differences often hold true in states that have been affected by outbreaks, although there is variation among the states, and small survey sample sizes limit the ability to identify statistically significant differences in some cases. In most of the affected states for which sufficient data are available, uninsured rates are higher among animal production workers than workers overall in a statistically significant way. For example, in Texas, 31% of animal production workers are uninsured compared to 19% of workers overall, and, in Ohio, 29% of animal production workers are uninsured compared to 7% of Ohio workers. Similarly, in four of the states (Kansas, Michigan, North Carolina, and Texas), animal production workers include a higher share of workers with LEP compared to workers overall. The share of animal production workers who are noncitizen immigrants is higher than workers overall in three of the states (Kansas, Michigan, and Texas). In some cases, differences between animal production workers and total workers within states may not be statistically significant due to smaller sample sizes, which limits the power to detect significant differences.

Across the affected states, there is variation in the characteristics of animal production workers largely reflecting overall demographic differences across states. For example, less than one in ten animal production workers in Ohio (4%) and South Dakota (8%) is Hispanic compared to nearly four in ten of their counterparts in Texas (37%), and the share who are noncitizen immigrants ranges from 5% in Ohio to 21% in Texas. The share of animal production workers who are uninsured ranges from 13% in Michigan and South Dakota to over one in four North Carolina (27%), Ohio (29%), and Texas (31%), and the share with LEP ranges from 6% in South Dakota to 19% in Texas.

Potential Future Actions

The federal government has recently announced several steps to try to address some of the potential health threats from the H5N1 outbreak. For example, on May 6, CDC announced an effort to provide personal protective equipment for affected workers, and on May 10, 2024, the USDA and CDC announced a package of incentives to support more testing and prevention at dairy farms in affected areas.

Efforts to address exposure and health threats posed by H5N1 could be complicated by challenges dairy farmworkers may face accessing health care and other services given that animal production workers are disproportionately likely to be noncitizen immigrants, uninsured, and have LEP. These challenges could be mitigated by providing information and resources to dairy farmworkers in linguistically accessible formats and utilizing trusted messengers who can help mitigate potential immigration-related fears, such as community health centers and community-based organizations. Providing these resources at no cost, including for people without health coverage, also could facilitate access.

The data further emphasize the potential value of tailored outreach approaches in each state to reflect varying demographics and needs across affected states as well as variation in state policies, which may impact workers’ overall access to health care and levels of immigration-related fears. For example, Colorado provides Marketplace coverage with premium subsidies to income-eligible people regardless of immigration status, while in the other affected states, undocumented immigrants are ineligible for federally funded or state coverage options. Two of the affected states (Texas and Kansas) have not implemented the ACA Medicaid expansion, resulting in more limited coverage options for low-income adults overall. In 2023, Texas passed legislation that would allow state and local police to question and arrest anyone they believe entered Texas through Mexico without authorization. While enforcement of the law is on hold pending court rulings, it likely contributes to increased uncertainty and fear among immigrants about interacting with officials.

On April 22, 2024, the Centers for Medicare and Medicaid Services (CMS) released a highly-anticipated final rule that creates new requirements for nurse staffing levels in nursing facilities, settings that provide medical and personal care services for 1.2 million Americans. CMS received nearly 50,000 comments on the proposed rule, ranging from comments that strongly supported the proposed standards to those that strongly opposed them. Among those comments, the nursing home industry suggested the rule was too strict and could lead to nursing facility closures, while resident and family advocates suggested the proposed standards were too weak to address well-documented concerns about substandard facility conditions, unattended residents, and poor patient care. The adequacy of staffing in nursing homes has been a longstanding issue, and the high mortality rate in nursing facilities during the COVID-19 pandemic highlighted and intensified the consequences of inadequate staffing levels.

This analysis discusses the provisions of the final rule, including changes made by the Administration from the proposed rule, and examines the percentage and characteristics of nursing facilities that currently meet the minimum staffing requirements in the final rule, which takes effect beginning in May 2026 for some facilities. The analysis estimates the percentage of facilities that could meet the requirements based on current staffing levels, examining the percent of facilities that meet all requirements—including 3.48 hours per resident day (HPRD), with 0.55 HPRD for RNs and 2.45 HPRD for nurse aides—and the percent that meet each requirement individually. In practice, facilities have several years to comply with the new requirements: the requirement to have overall staffing levels of 3.48 HPRD takes effect in 2026 for urban facilities and in 2027 for rural facilities, and the RN and nurse aide HPRD requirements take effect in 2027 for urban facilities and in 2029 for rural facilities. Facilities will also be allowed to apply for temporary exemptions from part or all of the final requirements if they meet certain conditions. The federal government estimates that a quarter of all 15,000 nursing facilities could end up obtaining an exemption.

This analysis uses Nursing Home Compare data from April 2024, which includes 14,448 nursing facilities (97% of all facilities, serving 1.18 million or 99% of all residents), and reflects staffing levels from October to December 2023. Due to data limitations, the analysis does not evaluate facilities’ ability to comply with other requirements in the final rule, including the requirement to always have a registered nurse on duty 24/7 or the ability to meet the new reporting and assessment requirements (see Methods).

Key takeaways include:

• Less than one in five (19%) of nursing facilities currently meet all three staffing minimums required in the final rule (Figure 1), which include 3.48 HPRD overall, 0.55 RN HPRD, and 2.45 NA HPRD. Nearly 60% of facilities would meet the interim requirement of an overall requirement of 3.48 HPRD.
• A smaller share of for-profit facilities currently meet all requirements in the final rule than non-profit and government facilities (11% versus 41% and 39%, respectively).
• Rural nursing homes are as likely as urban facilities to meet the final rule’s requirements based on current staffing levels, but rural facilities will have longer to comply with the new requirements.
• In over half of states, fewer than one-quarter of facilities meet all three staffing minimums required in the final rule. The share of facilities that meet the requirements ranges from 5% or lower in four states (AR, TN, TX, and LA) to 50% or higher in five states and D.C. (AK, ND, ME, DC, HI, and OR).

What are the major requirements in the final rule and how do they differ from the proposed rule?

There are many provisions of the final rule, which will be phased in over time. The first phase requirements are the same as the proposed rule and include enhanced facility-wide staffing assessment requirements, which will strengthen existing requirements by requiring facilities to: assess the needs of each resident, include input from nursing facility staff and residents’ families or legal representatives, and develop a plan to meet required staffing levels given residents’ needs. The final rule adds language to the proposed rule to require the active participation of the nursing home leadership and management and direct care workers in completing the assessments. The first phase will take effect on August 8, 2024, 90 days after publication of the final rule (which is 30 more days than were provided in the proposed rule).

The second phase of implementation requires nursing facilities to have a registered nurse on duty 24 hours a day and 7 days a week (24/7), but the final rule also requires facilities to have at least 3.48 HPRD of nursing care. Like the proposed rule, the second phase would take effect 2 years after publication of the final rule for urban nursing facilities (May 2026) and 3 years after publication of the final rule for rural nursing facilities (May 2027). Unlike the proposed rule, nursing facilities may apply for a hardship exemption from the 24/7 requirement, which would allow them to have a registered nurse on duty for only 16 hours per day. See below for more details about how facilities may apply for a hardship exemption.

The final phase of implementation requires nursing facilities to have a minimum of 0.55 registered nurse (RN) and 2.45 nurse aide HPRD in addition to the overall 3.48 HPRD requirement. Facilities could fulfill the requirement of the additional 0.48 HPRD with any nursing staff type, including nurse aides, RNs, or licensed practical nurses (LPNs). The third phase would take effect 3 years after publication of the final rule for urban nursing facilities (May 2027) and 5 years after publication of the final rule for rural nursing facilities (May 2029).  These requirements are unchanged from the proposed rule.

The final rule includes hardship exemptions that allow nursing facilities to maintain lower staffing levels, but includes additional requirements tied to those exemptions. Nursing facilities may apply for exemptions from any of the minimum staffing requirements if they are located in an area with workforce unavailability (defined as having a provider to population ratio that is at least 20% lower than the national average). The final rule eliminated a provision in the proposed rule that would have allowed nursing facilities to apply for an exemption if they were located at least 20 miles from the nearest nursing facility, regardless of workforce availability. Nursing facilities would also have to demonstrate good faith efforts to hire and retain staff and a financial commitment to staffing by reporting the total amount of money spent on direct care staff. Finally, facilities would be ineligible for an exemption if they had any staffing-related violations including a failure to submit required data, being identified as a Special Focus Facility (a federal designation provided to facilities with a history of serious quality issues – see Box 1), or having violations related to insufficient staffing.

Nursing facilities that receive hardship exemptions will be required to:

• Post a notice of its hardship exemption status in a “prominent and publicly viewable location,”
• Share information about its exemption status and the degree to which it is not in compliance with the staffing requirements to current and prospective residents, and
• Send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

The final rule also notes that exemption information will be publicly available on Care Compare in an effort to provide transparency and provide additional information that consumers, families, and caregivers may use to compare nursing facilities in their area. The federal government estimates that a quarter of all 15,000 nursing facilities could end up obtaining exemptions for at least some of the requirements.

The final rule includes other requirements as part of a broader efforts to address quality and staffing in nursing facilities. Those requirements are nearly the same as in the proposed rule. The final rule:

• Requires state Medicaid agencies to report the percent of Medicaid payments for institutional long-term services and supports (LTSS) that are spent on compensation for direct care workers and support staff. This aligns with a similar requirement for home and community-based LTSS that was enumerated in the final rule on access to care in Medicaid in a broader effort to increase transparency.
• Eliminates a requirement from the proposed rule to report the data by type of delivery system (fee-for-service versus managed care) to reduce the administrative burden on states.
• Includes $75 million in financial incentives such as scholarships and tuition reimbursement for individuals to enter careers in nursing homes. CMS aims to balance the goal of establishing stronger staffing requirements against the practicalities of implementation and costs.

What share of nursing facilities currently meet minimum staffing requirements in the final rule?

KFF estimates that 19% of nursing facilities currently meet all three staffing hour minimums required in the final rule (3.48 HPRD overall, 0.55 RN HPRD, and 2.45 NA HPRD). (Figure 1). The interim requirement that nursing facilities must meet is 3.48 HPRD, among all types of nursing staff. The final requirements retain the total minimum hours of care but specify that of that total, there must be at least 0.55 HPRD of RN care and 2.45 HPRD of nurse aide care. Facilities may use any type of nursing care to fulfill the final 0.48 hours. Nearly 60% of facilities have staffing levels at least equal to the interim requirement of 3.48 HPRD, but fewer (19%) of facilities currently meet all staffing requirements, including the minimum number of hours of RN and nurse aide care that are required when the rule is fully implemented (49% and 30% respectively). Though higher shares of facilities meet the overall, RN, and nurse aide requirements individually, the share that meet all three requirements is substantially lower since facilities could meet one or two requirements without meeting the other(s). Facilities that need to hire new RNs to comply with the final rule may find it difficult to compete with hospitals, many of which are also trying to increase the number of RNs they employ. The rule estimates that to meet both the 24/7 RN and 0.55 RN HPRD requirements, facilities would need to hire about 16,000 RNs. To meet the 2.45 nurse aide HPRD requirements, CMS estimates that facilities would need to hire 35,306 nurse aides. CMS states that the existing survey, certification, and enforcement processes will be used to assess compliance, with more details to come.

Only 11% of for-profit nursing facilities currently meet all three staffing minimums required in the final rule compared with 41% of non-profit facilities and 39% of government facilities  (Figure 2). There are approximately 10,500 for-profit nursing facilities (73% of all nursing facilities); 3,000 non-profit nursing facilities (21%); and 900 government-owned nursing facilities (6%). When looking at the ownership of facilities that meet the interim requirement of 3.48 HPRD requirement, fewer for-profit facilities would meet the 3.48 overall standard than non-profit and government facilities (52%, 79%, and 71%, respectively; data not shown). Similarly, for-profit facilities are less likely to meet the registered nurse and nurse aide requirements when compared with government and for-profit facilities (data not shown).

The percentage of nursing facilities that currently meet the final rule’s requirements are similar in rural and urban areas, but rural facilities will have longer to comply with the new requirements (Figure 3). In rural areas, 20% of nursing facilities have staffing levels that would meet the rule’s requirements compared to 18% in urban areas. Despite similar levels of current staffing, nursing facilities in urban areas will need to comply with all of the provisions in the final rule two years earlier than those in rural areas (May 2027 and May 2029 respectively). In the rule, CMS cites that “rural areas face a myriad of challenges ranging from worker housing shortages to severe transportation challenges for remote facilities that are unique to their location.” Both rural and urban facilities face challenges with hiring but perhaps for different reasons. Rural facilities may have difficulty finding staff because there are fewer available workers, while urban facilities may have difficulty because available workers have more low-wage jobs to choose from in urban areas. Despite those different challenges, staffing patterns in urban and rural facilities are remarkably similar (data not shown).

In over half of states, fewer than a quarter of facilities would meet all three HPRD provisions in the final rule (Figure 4). The five states with the most nursing facilities (Texas, California, Ohio, Florida, and Illinois) all fall into this category, skewing the national average down to 19%. In six states, over half of facilities would meet these provisions, and in the remaining 17 states, 25-49% of facilities would meet the provisions. Variation across the states reflects many factors including what percentage of facilities are for-profit, the availability of RNs and nurse aides in the state, and state requirements regarding minimum staffing levels.

Among the 503 Special Focus Facilities (SFF) & SFF candidates (facilities with a history of serious quality issues), only 9% have staffing levels that would meet the requirements in the final rule (Figure 5). CMS established the Special Focus Facility program in 1998 to improve care in the poorest performing nursing homes that have a history of serious quality issues. To avoid poor-quality facilities receiving exemptions from the staffing minimums, the final rule states that Special Focus Facilities are not eligible for an exemption to the provisions in the final staffing rule. These facilities are described as having a “yo-yo” compliance history, meaning that even when these facilities correct problems identified on one inspection, they often have significant problems by the time the next inspection occurs. These repeated quality issues arise because the facilities rarely address underlying systemic problems, which can lead to cycles of serious deficiencies and pose risks to residents’ health and safety. For SFFs, state agencies conduct a full, onsite inspection of all health and safety requirements every six months, and recommend progressive enforcement (e.g., civil money penalty, denial of federal funds, etc.) until the facility either (1) graduates from the SFF program; or (2) is terminated from the Medicare and/or Medicaid program(s). Due to resource constraints, the SFF designation is limited to a certain number of nursing facilities. States also have the option to designate facilities as SFF candidates, with a maximum of 30 SFF candidates per state. Once an SFF graduates or is terminated, the state selects a new SFF from the list of candidates.

CMS estimates that complying with the final rule will cost $43 billion in the 10 years after the final rule takes effect. Since the rule was released, prominent labor unions have applauded its release while the nursing home industry has issued statements criticizing its finalization and other groups have expressed concerns about the high costs the rule may create for nursing homes and states. Labor unions commended the elements of the rule, noting that it was long overdue and would go a long way in protecting the residents and staff that live and work in nursing facilities. From the industry, there has been criticism related to funding of the rule and workforce shortages. The cost of implementing the staffing requirements has been raised as a major concern by the nursing home industry, among others. For nursing facilities, hiring and retaining sufficient staff will increase their operational costs. Such costs are likely to be passed on to public and private payers for nursing facility services including residents and family members, Medicaid and Medicare. Medicaid is the single largest payer for nursing facilities so increased costs could have implications for state budgets as well as federal spending. The rule also requires state Medicaid agencies to report on the percent of Medicaid payments for institutional long-term services and supports (LTSS) that are spent on compensation for direct care workers and support staff, which is similar to a requirement for home-and-community based LTSS.

The final rule includes few details on enforcement, though CMS states that the existing survey, certification, and enforcement processes will be used to assess compliance. According to the final rule, CMS intends to publish more details on how compliance will be assessed in advance of each implementation date for different components of the rule. Forthcoming decisions about enforcement of the new staffing requirements and the ease with which nursing homes are able to receive hardship exemptions may impact the extent to which the final rule has its desired effect on the quality of care for nursing home residents. The need for nursing facility care is also likely to increase as the population continues to age, which may intensify these unintended consequences.

Note: This analysis was updated on May 17, 2024 to include new data.

Inflation in medical care prices and overall health spending typically outpaces inflation in the rest of the economy. However, since 2021, medical prices have grown at a similar rate as in past years while prices in some other parts of the economy grew much more rapidly than in the past.

While medical care prices increased by 2.2% between March 2023 and March 2024, the prices of all goods and services increased by 3.5%, according to an updated analysis. Prices for hospital services and related services (7.7%) – both inpatient (6.9%) and outpatient (8.3%) – as well as for nursing homes (3.9%) rose faster than for prescription drugs and physicians’ services (0.4% and 0.7%, respectively).

KFF uses Bureau of Labor Statistics (BLS) data, including the consumer price index (CPI) and producer price index (PPI) to analyze prices for medical care compared to other goods and services. The analysis can be found on the Peterson-KFF Health System Tracker, an information hub dedicated to monitoring and assessing the performance of the U.S. health system.