How Many Older Adults Live in Poverty?

Authors: Nancy Ochieng, Juliette Cubanski, Tricia Neuman, and Anthony Damico
Published: May 21, 2024
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Issue Brief

Social Security payments and Supplemental Security Income have been instrumental in providing economic security for older adults in the US. Additionally, Medicare, which provides health insurance to 66 million people age 65 or older and younger adults with long-term disabilities, offers financial protection by helping to cover the cost of medical care, while Medicaid provides additional benefits and cost-sharing assistance to many Medicare beneficiaries with low incomes. Despite these economic and health supports, many older adults live on relatively low incomes. The average Social Security benefit is around $1,900 per month, but millions of retired workers and their spouses receive much less than that, because of lower wages earned during their working years or because they claimed benefits before their full retirement age. (A small share of older adults in the U.S. are not eligible to receive Social Security benefits at all.) And though the peak of high inflation from 2022 has subsided, prices on many consumer goods and services have not declined to previous levels, posing a threat to the financial security of many individuals ages 65 and older who live on fixed incomes.

To provide context for understanding the financial needs and well-being of older adults, this brief analyzes the latest data on poverty rates among the 58 million non-institutionalized adults ages 65 and older in the U.S overall, based on both the official poverty measure and the Supplemental Poverty Measure, as reported by the Census Bureau. To measure poverty under the official measure, the Census Bureau uses specific dollar thresholds, which vary by family size and age of family members but do not vary geographically. In 2022, the poverty threshold was $14,040 for a single person age 65 or older and $17,710 for a household of two people 65 or older. In contrast to the official poverty measure, the Supplemental Poverty Measure accounts for geographic area and homeownership status and also reflects financial resources and liabilities, including out-of-pocket medical spending, taxes, and the value of in-kind benefits (e.g., food stamps). For 2020 and 2021, the Supplemental Poverty Measure also incorporated temporary COVID-19-related financial resources provided to individuals, such as stimulus payments. (See Appendix for more details on both measures). (The Census Bureau poverty thresholds analyzed in this brief are different from the Health and Human Services (HHS) poverty guidelines that are used to determine income eligibility for certain programs).

The analysis examines poverty rates among older adults at the national level in 2022, the most recent year available. It uses three-year averages (2020-2022) for poverty estimates by demographic characteristics (age, gender, race/ethnicity, health status) and at the state level. Because the Supplemental Poverty Measure accounted for temporary COVID-19-related payments in 2020 and 2021, the estimates for demographic groups and states based on the three-year averages are lower relative to the national Supplemental Poverty Measure poverty rate for 2022. This brief also assesses trends in poverty rates among older adults over the 10-year period between 2013 and 2022.

Key Takeaways

  • About 6 to 8 million adults ages 65 and older were living in poverty in 2022, depending on the measure used to assess poverty. Under the official poverty measure, one in 10 (10.2%), or 5.9 million adults ages 65 and older, had incomes below the official poverty threshold of $14,040 in 2022. The poverty rate was higher based on the Supplemental Poverty Measure, 14.2% or 8.2 million older adults, primarily because the Supplemental Poverty Measure takes into account out-of-pocket medical expenses that are not incorporated in the official poverty measure.
  • Among adults ages 65 and older, the poverty rate was higher among people ages 80 and older, women, people of color, and people in relatively poor health under both the official and supplemental poverty measures. For example, based on the official poverty measure, the share of older Black (17.3%), Hispanic (17.4%) and American Indian or Alaska Native (17.4%) adults with incomes below poverty was more than double the share of older White adults (7.7%).
  • The share of people ages 65 and older with incomes below the official poverty measure varied by state, ranging from 4.5% in Wisconsin to 20.3% in the District of Columbia (and from 4.2% in Iowa to 22.0% in the District of Columbia based on the Supplemental Poverty Measure). The share of older adults living below twice the poverty level ranged from 18.4% in Maryland to 41.7% in West Virginia based on the official poverty measure, and from 28.3% in Iowa to 49.3% in the District of Columbia based on the Supplemental Poverty Measure.
  • Between 2013 and 2022, the poverty rate among older adults remained relatively stable based on the official poverty measure, around 10%. Based on the Supplemental Poverty Measure, the poverty rate among older adults was also fairly stable from 2013 to 2019 – and higher than under the official poverty measure – but dropped from 12.8% in 2019 to 9.5% in 2020 and 10.7% in 2021 due to COVID-19 related payments, before increasing to 14.2% in 2022 with the expiration of many of these pandemic-related relief funds.

What Share of Older Adults Lived in Poverty in 2022?

In 2022, a larger share of people ages 65 and older were living in poverty based on the Supplemental Poverty Measure (14.2%) than the official poverty measure (10.2%), a difference largely due to the fact that the Supplemental Poverty Measure accounts for additional financial resources and expenses—such as out-of-pocket medical expenses—that are not included in official poverty measure does not. Because older adults typically have higher medical out-of-pocket costs than younger people, this translates to higher poverty rates under the Supplemental Poverty Measure than the official poverty measure.

  • 100% of poverty: Under the official poverty measure, one in 10 (10.2%) or 5.9 million people ages 65 and older had incomes below the poverty threshold of $14,040 in 2022. The share and number of people living in poverty are higher, 14.2% or 8.2 million older adults, based on the Supplemental Poverty Measure (Figure 1, Appendix Table 1).
  • 200% of poverty: In 2022, nearly three in 10 (29.4%, or 17.0 million) adults ages 65 and older had incomes below 200% of poverty under the official measure ($28,080 in 2022). The share is higher – more than four in 10 (42.2%) older adults, or 24.4 million people – based on the Supplemental Poverty Measure.
One in 10 (10.2%) Adults Ages 65 and Older Had Incomes Below Poverty in 2022, Based on the Official Measure, But the Rate Was Higher (14.2%) Under the Supplemental Poverty Measure

How Do Poverty Rates Among People Ages 65 and Older Vary by Demographic Characteristics?

Under both the official poverty measure and the Supplemental Poverty Measure, the poverty rate among people ages 65 and older was higher among adults ages 80 and older, women, and people self-reporting fair or poor health, based on three-year averages for 2020-2022. Additionally, larger shares of older Black, Hispanic, American Indian or Alaska Native, Asian, and people identifying as multiple races had incomes below poverty compared to White adults ages 65 and older, based on both measures. The rate of poverty and the number of people living in poverty was higher for most demographic subgroups under the Supplemental Poverty Measure than under the official poverty measure, except for older Black and American Indian or Alaska Native adults, and adults reporting fair or poor health, where rates between both measures were similar. These three-year average estimates include two years (2020 and 2021) when the Supplemental Poverty Measure accounted for temporary COVID-19-related payments to individuals.

Poverty Rates Among Older Adults Increase With Age

Among people ages 65 and older, the poverty rate was higher among people ages 80 and older than younger people ages 70-79 years and 65-69 years, based on both the official poverty measure (12.1% vs. 9.1 and 9.3%, respectively) and the Supplemental Poverty Measure (14.3% vs. 10.6% and 10.4% respectively) (Figure 2, Appendix Table 1).

Overall, 1.5 million adults ages 80 and older lived in poverty under the official measure, compared with 2.3 million adults ages 70-79 years and 1.7 million adults ages 65-69 (the numbers living in poverty based on the Supplemental Poverty Measure were 1.8 million, 2.7 million, and 1.9 million, respectively).

Notably, nearly half of adults ages 80 and older, or 6.0 million, had incomes below 200% of poverty under the Supplemental Poverty Measure, compared to 34.2% of those ages 65-69.  Similar to the official poverty measure, a larger share of adults ages 80 and older than those ages 65-69 and 70-79 had incomes below 200% of poverty.

Among Adults Ages 65+, the Poverty Rate Was Higher Among People Ages 80 and Older Than Those Ages 65-79

Poverty Is Higher Among Older Women Than Older Men

The poverty rate was higher among women than men ages 65 and older, based on both the official measure (11.0% vs. 8.5%) and the Supplemental Poverty Measure (12.4% vs.10.2%) (Figure 3, Appendix Table 1). In absolute numbers, more older women than older men (3.2 million vs 2.2 million) lived in poverty under the official measure, and under the Supplemental Poverty Measure (3.8 million vs 2.6 million). Similarly, a larger share of women ages 65 and older than older men had incomes below 200% of poverty under both measures.

Additionally, among people ages 80 and older, a higher share of women lived in poverty compared with men based on both the official poverty measure (14.0% vs. 9.2%) and the Supplemental Poverty Measure (16.2% vs 11.7%).

Larger Shares of Women Ages 65 and Older Had Incomes Below Poverty Than Older Men, Based on Both Measures of Poverty

Among Older Adults, Poverty Rates Are Higher Among People of Color Than Among White Adults

Among people ages 65 and older, the poverty rate was higher among Black, Hispanic, American Indian or Alaska Native, Asian, and people identifying as multiple races compared with White adults based on both measures. Based on the official poverty measure, the share of older Black (17.3%), Hispanic (17.4%) and American Indian or Alaska Native (17.4%) adults with incomes below poverty was more than double the share of older White adults (7.7%) (Figure 4, Appendix Table 1). The pattern was consistent under the supplemental poverty measure (for example,17.3% of older Black and 20.0% of older Hispanic adults lived in poverty vs. 9.2% of older White adults).

Similarly, larger shares of older Black, Hispanic, American Indian or Alaska Native, Asian, and people identifying as multiple races had incomes below 200% of poverty than older White adults, based on both measures.

Poverty rates by both race and ethnicity and gender mirrored the overall pattern. For example, poverty rates among older Black, Hispanic, and American Indian or Alaska Native women were twice as high as those among older White women, based on the official measure (Appendix Tables 1 and 2).

The Poverty Rate Was Higher Among People of Color Ages 65 and Older, Particularly Black, Hispanic, and American Indian and Alaska Native Adults, Than White Older Adults

Poverty Is Higher Among Older Adults Reporting Fair or Poor Health Than Those in Excellent or Very Good Health

The poverty rate was substantially higher among adults ages 65 and older in fair or poor self-reported health than older adults in excellent or very good health, based on both the official measure (16.0% vs. 5.9%) and the supplemental poverty measure (16.8% vs. 7.7%) (Figure 5, Appendix Table 1).

Similarly, larger shares of older adults in fair or poor health had incomes below 200% of poverty compared with older adults in excellent or very good health, based on both measures.

The Poverty Rate Among Adults Ages 65 and Older Increased as Self-Reported Health Status Worsened and Was Highest for those in Fair or Poor Health

How Do Poverty Rates Among People Ages 65 and Older Vary by State?

The poverty rate among people ages 65 and older varied by state, based on three-year averages for 2020-2022.

  • 100% of poverty: Under the official poverty measure, the poverty rate ranged from 4.5% in Wisconsin to 20.3% in the District of Columbia and was 10% or higher in 17 states and the District of Columbia (Figure 6, Appendix Table 3). Under the Supplemental Poverty Measure, the poverty rate ranged from 4.2% in Iowa to 22.0% in the District of Columbia and was 10% or higher in 25 states and the District of Columbia.
  • 200% of poverty: Under the official poverty measure, the share of older adults with incomes under 200% of poverty ranged from 18.4% in Maryland to 41.7% in West Virginia; a third (33%) or more of older adults had incomes below 200% of poverty in 11 states and the District of Columbia (Appendix Table 4). Under the Supplemental Poverty Measures, the share of older adults under 200% of poverty ranged from 28.3% in Iowa to 49.3% in the District of Columbia; a third or more of older adults had incomes below 200% of poverty in 34 states and the District of Columbia.
  • Comparing poverty rates under both measures: The poverty rate for adults ages 65 and older was similar under both the official poverty measure and the Supplemental Poverty Measure in all but six states, likely due to the COVID-19 stimulus payments and one-time state income tax rebates factored in the supplemental poverty measure in 2020 and 2021. But in California, Florida, Hawaii, Maryland, New Jersey, and Texas, the poverty rate was higher under the Supplemental Poverty Measure than under the official poverty measure. For example, in California, 16.0% of older adults were living in poverty under the Supplemental Poverty Measure versus 10.8% under the official measure; in Texas, the rates were 13.3% versus 11.4%. Higher Supplemental Poverty Measure rates in these six states could be influenced by specific state-level factors such as housing costs, which are also factored into how poverty is determined under the Supplemental Poverty Measure.
The Poverty Rate Among Adults Ages 65 and Older Varies by State and Poverty Measure

Between 2013 and 2022, the official poverty rate among older adults was mostly unchanged but dipped in 2020 and 2021 under the Supplemental Poverty Measure due to the availability of COVID-19-related economic stimulus payments and then increased in 2022 when these payments ended. Over the 10-year period between 2013 and 2022, the official poverty rate was relatively stable, increasing modestly from 9.5% in 2013 to 10.2% in 2022 (Figure 7). The poverty rate under the Supplemental Poverty Measure was also fairly stable from 2013 to 2019—and higher than under the official measure—before dropping in 2020 and 2021, years when the Supplemental Poverty Measure accounted for resources that were aimed at mitigating the financial impact of the COVID-19 pandemic. According to the Census Bureau, in 2020, 2.0 million adults ages 65 and older were lifted out of poverty due to COVID relief funds, and 1.9 million in 2021. The Supplemental Poverty Measure poverty rate among older adults decreased from 12.8% in 2019 to 9.2% in 2020 and 10.7% in 2021, and then increasing to 14.2% in 2022, reflecting the expiration of many of these pandemic-related relief funds.

While the poverty rate remained similar under both the official measure and the Supplemental Poverty Measure in 2022 compared to 2013, the number of older adults living in poverty increased over this 10-year period – by 1.7 million under the official measure and 1.6 million under the Supplemental Poverty Measure. This was driven by an overall increase in the number of older adults in the U.S.

Under the Supplemental Poverty Measure, the Poverty Rate Among Older Adults Increased in 2022 After a Two-Year Decline Due to Expiration of Temporary COVID-19 Relief Funds

This work was supported in part by AARP. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Nancy Ochieng, Juliette Cubanski, and Tricia Neuman are with KFF. Anthony Damico is an independent consultant.

Methods

This analysis reports poverty data for 2020-2022 using the 2021-2023 Current Population Survey March Annual Social and Economic Supplement (CPS ASEC) for the estimates of poverty under the official measure, and the Supplemental Poverty Measures Public Use Research Files, which are derived from the CPS ASEC, for poverty estimates under the Supplemental Poverty Measure. The 2023 CPS ASEC was used for national estimates (data for 2022); the 2021-2023 CPS ASEC was used for state-level and subgroup estimates (averaged across the three years, 2020-2022). Standard errors were calculated using the replicate weights and a Fay’s adjustment. All reported estimates have a relative standard error below 30%. Any estimate with a relative standard error greater than 30% is considered unreliable and not reported.

The poverty rates presented in this brief apply to non-institutionalized people ages 65 and older, and not the total Medicare population, which includes both people ages 65 and older and younger people with permanent disabilities, and both facility residents and people living in the community. The CPS ASEC does not include older adults residing in institutions, such as nursing homes and other long-term care facilities. Rates of poverty among the total Medicare population would be larger than the estimates presented here because income levels are lower among both Medicare beneficiaries under age 65 with disabilities and those living in long-term care facilities.

This analysis compares the incomes of family units to poverty thresholds, consistent with the approach defined by the official measure and the Supplemental Poverty Measure (although each measure defines families somewhat differently). Relying on a unit of measurement other than family units could produce different poverty rates. For example, health insurance units tend to be smaller than family units, and poverty rates may be much higher when based on the former. Further, the Census Bureau poverty thresholds analyzed in this brief are different from the Health and Human Services (HHS) poverty guidelines (sometimes referred to as the “federal poverty level”) that are used to determine income eligibility for certain programs.

Finally, estimates in this brief from the Public Use Research Files may not precisely align with those published by the Census Bureau due to disclosure protections such as topcoding. Additionally, the use of pooled three-year estimates for demographic and state-level data yields slightly different results compared to single-year estimates published elsewhere.

Differences in methodology between the official measure and the Supplemental Poverty Measure: The official measure and SPM produce different estimates of poverty because their methodology varies in several ways. Both measures determine poverty estimates by comparing the financial resources of families against poverty thresholds, which are minimum dollar amounts needed to meet basic needs. These thresholds vary by family size and composition. While the official measure defines resources as cash income, the Supplemental Poverty Measure accounts for resources other than cash (e.g., in-kind government benefits) and expenses (e.g., out-of-pocket medical expenses). The differences in methodology between both measures are summarized below (Table 1):

Differences in Methodology Between the Official Poverty Measure and the Supplemental Poverty Measure

Changes to the methodology of the Supplemental Poverty Measure beginning in 2019: In 2021, the Supplemental Poverty Measure methodology of estimating both resources and thresholds was revised, and these changes were implemented starting in the 2019 thresholds. A summary of the changes is below (Table 2):

Summary of Changes to the Methodology of the Supplemental Poverty Measure

Appendix

Adults Ages 65 and Older With Incomes Below 100% of Poverty Under Official and Supplemental Poverty Measures, by Selected Characteristics
Adults Ages 65 and Older With Incomes Below 200% of Poverty Under Official and Supplemental Poverty Measures, by Selected Characteristics
Adults Ages 65 and Older With Incomes Below 100% of Poverty Based on the Official and Supplemental Poverty Measures, by State
Adults Ages 65 and Older With Incomes Below 200% of Poverty Based on the Official and Supplemental Poverty Measures, by State
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News Release

In 45 States, Fewer Than Half of Nursing Facilities Have Enough Staff to Meet New Federal Requirements

Current staffing levels are similar in rural and urban nursing facilities, but urban facilities will have less time to comply with the new requirements

Published: May 21, 2024

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.

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Who is at Risk Amid the H5N1 Influenza Outbreak? Characteristics and Health Coverage of Animal Production Workers

Published: May 21, 2024

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%).

Characteristics of U.S. Animal Production Workers and Total Workers, 2022

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.

Characteristics of Animal Production Workers and Total Workers in States Affected by the H5N1 Outbreak, 2022

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.

Methods

The data in this brief are based on KFF analysis of the 2022 American Community Survey one-year Public Use Microdata Sample (PUMS). Animal production workers are defined as individuals currently working in industry code 0180: Animal Production and Aquaculture. We exclude those working in occupation codes 6005 (first-line supervisors of farming, fishing, and forestry workers), 6010 (agricultural inspectors), 6040 (graders and sorters, agricultural products), 6115 (fishing and hunting workers), 6120 (forest and conservation workers), and 6130 (logging workers).

One in four animal production workers are found in Texas (10%), California (8%), and WI (7%), with the remaining workers spread across the remaining states. Among the nine states with H5N1 infected cattle herds, the sample sizes are generally small (<300), which can impact the reliability of the estimates due to larger standard errors. Results for Idaho and New Mexico are not shown here due to insufficient sample size (<100).

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A Closer Look at the Final Nursing Facility Rule and Which Facilities Might Meet New Staffing Requirements

Published: May 21, 2024

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).
About 1 in 5 Nursing Facilities Currently Meet the Staffing Requirements in the Final Rule (When Fully Implemented)

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).

For-Profit Nursing Facilities Would Be Least Likely to Meet the Staffing Requirements in the Final Rule

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).

Similar Shares of Rural and Urban Nursing Facilities Currently Meet the Staffing Requirements in the Final Rule

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.

In Over Half of States, Less Than a Quarter of Nursing Facilities Currently Meet the Staffing Requirements in the Final Rule (When Fully Implemented)

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.

Lower Shares of Special Focus Facilities Currently Meet the Staffing Requirements in the Final Rule When Compared to Non-Special Focus Facilities

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.

Methods

This analysis uses Nursing Home Compare as of April 2024 and reflects staffing levels from October 2023 to December 2023. Nursing Home Compare is a publicly available dataset that provides a snapshot of information on quality of care and key characteristics for approximately 14,900 Medicare and/or Medicaid-certified nursing facilities. This analysis drops about 3% of nursing facilities, including the facilities in Guam and Puerto Rico and nursing facilities for which there was not staffing data available for the fourth quarter of 2023, for a total analytic sample of 14,448 facilities. The number of facilities identified in this analysis as meeting/not meeting requirements may differ from CMS’ estimates due to different years and quarters of data used for estimates.

In Figure 3, the analysis uses the Office of Management and Budget’s (OMB) delineation of metropolitan and micropolitan statistical areas to designate rural and urban areas. Urban and rural facilities have different timelines to come into compliance with the rule, but the analysis reflects compliance rates if the HPRD requirements were in effect now for all facilities.

Due to the limitations of publicly available data, this analysis does not look at facilities that meet the requirement to have an RN on staff 24 hours a day, seven days a week (24/7). Nursing home staffing data is calculated from the Payroll Based Journal (PBJ), which includes data on the total number of RN hours worked per day at a facility, but no data on the timing of shifts. This limits our understanding of whether shifts were worked simultaneously by multiple employees (possibly not fulfilling the 24-hour requirement) or whether those hours were spread out over a 24-hour period (fulfilling the 24-hour requirement). CMS estimates that close to 80% of nursing facilities would already meet the RN 24/7 requirement. It is unclear how the agency estimated whether nursing facilities had RNs on staff 24/7 or what data they used to do so.

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How Does Medical Inflation Compare to Inflation in the Rest of the Economy?

Authors: Shameek Rakshit, Emma Wager, Cynthia Cox, Paul Hughes-Cromwick, and Krutika Amin
Published: May 17, 2024

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.

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Poll Finding

Language Barriers in Health Care: Findings from the KFF Survey on Racism, Discrimination, and Health

Authors: Ana Gonzalez-Barrera, Liz Hamel, Samantha Artiga, and Marley Presiado
Published: May 16, 2024
Section:
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Findings

In the U.S., there are about 26 million people who have limited English proficiency (LEP), meaning they speak English less than very well, making up about 8% of people ages five and older. Most U.S. adults with LEP speak Spanish (62%), followed by Chinese (7%), Vietnamese (3%), Arabic (2%), and Tagalog (2%), with the remainder speaking a variety of different languages from regions across the world.  Hispanic people account for nearly two-thirds (62%) of the LEP population, while over a fifth (22%) of individuals with LEP are Asian. The remainder of individuals with LEP are White (11%) or Black (4%) or of other racial and ethnic backgrounds. Adults with LEP are also more likely to be low-income—nearly one in five individuals with LEP have family income below 200% of the federal poverty level, compared with one in ten English-proficient individuals. This brief examines health care experiences among U.S. adults with LEP, drawing on findings from the KFF Survey on Racism, Discrimination, and Health.1  For more information about U.S. immigrants with LEP, see this brief. The data identify ongoing barriers and disparities adults with LEP face in accessing health care and suggest that having access to providers who speak their preferred language helps reduce these barriers and may improve certain health care experiences.

Health and Health Care Experiences Among Adults with LEP

Adults with LEP report worse health status and increased barriers in accessing health care compared to English proficient adults.2  Adults who have LEP are more likely to report their physical health as “fair” or “poor” compared with adults who are English proficient (34% vs. 19%). Despite this difference in health status, adults with LEP report less use of care and greater barriers to accessing health care compared to their English proficient counterparts. Adults who have LEP are less likely to say they had a health care visit in the past three years than English proficient adults (86% vs. 95%). In addition, consistent with other analysis, adults who have LEP are more likely than those who are English proficient to report being uninsured (33% vs. 7%). They also are less likely to say they have a usual source of care other than the emergency room (74% vs. 88%). Notably, four in ten adults with LEP (39%) say their usual source of care is a neighborhood clinic or health center, highlighting the importance of community health centers in providing linguistically appropriate and culturally competent care.

Adults With Limited English Proficiency More Likely to Say They Are in Fair or Poor Health Than Those Who Are English Proficien

About half of adults with LEP say they encountered at least one language barrier in a health care setting in the last three years. This includes about a third of LEP adults who say there was a time in the past three years when difficulty speaking or reading English made it hard for them to fill out forms for a health care provider (34%) or communicate with medical office staff (33%), three in ten who report difficulty understanding a health care provider’s instructions (30%), and about a quarter who say language barriers made it difficult to fill a prescription or understand how to use it (27%) or schedule a medical appointment (25%).

About a Third of Adults With Limited English Proficiency Say They Have Faced Language Barriers When Seeking Health Care

Adults with LEP report having positive, respectful interactions with health care providers somewhat less frequently compared to those who are English proficient. Overall, most adults report having mostly positive interactions with health care providers in the past three years, with majorities regardless of English proficiency saying their providers explained things in a way they could understand, spent enough time with them, understood and respected their cultural beliefs, and involved them in decision-making at least most of the time. However, adults with LEP report some of these experiences less frequently compared to those who are English proficient, including a provider explaining things in a way they could understand (81% vs. 89%), spending enough time during visits (68% vs. 76%), and involving them in decision-making about their care (63% vs. 82%).

Adults With LEP Are Somewhat Less Likely Than English-Proficient Adults To Report Certain Positive Interactions With Health Care Providers

Adults with LEP express lower levels of comfort asking questions of their health care providers compared to those who are English proficient. While most adults, regardless of English proficiency, say they have felt at least “somewhat” comfortable asking doctors and other health care providers questions about their health or treatment in the past three year, about half (54%) of adults with LEP say they feel “very comfortable,” which is lower than the two-thirds (66%) of English proficient adults who say the same.

Nearly Half of Adults With Limited English Proficiency Say They Have Prepared for Insults or Been Careful About Their Appearance During Health Care Visits in the Past Three Years

About one in five adults with LEP report a negative experience with a provider, one in eight report being treated unfairly or with disrespect, and about half report practicing vigilant behaviors associated with health care visits. Among adults with LEP, one in five reports experiencing at least one of several negative experiences with a health care provider in the past three years, including a provider ignoring a direct request or question (11%), assuming something about them without asking (8%), suggesting they were personally to blame for a health problem (8%), or refusing to prescribe needed pain medication (8%). In addition, one in eight (13%) adults with LEP say there was a time in the past three years when a health care provider or their staff treated them unfairly or with disrespect because of their race or ethnic background or for some other reason. Reflecting these experiences, about half (48%) of adults with LEP say they feel they have to be very careful about their appearance in order to be treated fairly (44%) and/or prepare for possible insults from a provider or their staff (18%) at least some of the time during health care visits. Adults with LEP do not report these experiences at significantly higher rates compared with those who are English proficient.

Importance of Linguistically Concordant Care

Nearly four in ten adults with LEP say fewer than half of their recent health care visits were with a provider who spoke their preferred language. While six in ten (63%) adults with LEP say at least half of their health care visits in the past three years were with a doctor or health care provider that spoke their preferred language, just 28% say that all of them were. Almost four in ten (37%) say that fewer than half of their visits were with a language concordant provider, including 15% who say they had no health care visits in the past three years with a provider who spoke their preferred language. In addition, among adults with LEP, four in ten say fewer than half of their health care visits in the past year were with a provider who shared their racial and ethnic background.

Nearly Four in Ten Adults With LEP Say Fewer Than Half of Their Recent Health Care Visits Were With a Provider Who Spoke Their Preferred Language

Adults with LEP who have more visits with providers who speak their preferred language are less likely to report facing language barriers while getting health care. Overall, four in ten LEP adults who say at least half of their health care visits in the past three years were with a provider who spoke their preferred language report experiencing at least one language barrier, compared with six in ten among those who had fewer than half of their health care visits with a language-concordant provider. For example, 45% of LEP adults who say less than half of their health care visits were with a provider who spoke their preferred language say they had trouble communicating with medical office staff, compared with 26% of those who had half or more of their health care visits with a language concordant provider.

Adults With LEP Report Fewer Language Barriers in Health Care Settings When They See More Providers Who Speak Their Preferred Language

Adults with LEP who have more visits with a provider who speaks their preferred language are more likely to say they are comfortable asking questions about their health and treatment compared to those with fewer visits with a language concordant provider. Six in ten (61%) LEP adults who had at least half their visits with providers who spoke their preferred language say they have felt very comfortable asking questions compared to four in ten (43%) of those who had fewer visits with a language concordant provider.

Adults With LEP Who Have More Visits With Providers Who Speak Their Language Are More Likely To Feel Very Comfortable Asking Questions About Health or Treatment

Adults with LEP who have more visits with language-concordant providers are more likely to say their providers usually respect their cultural values and beliefs and ask them about social factors like access to work, food, and housing. Among adults with LEP, those who had at least half of their health care visits with a provider who spoke their preferred language are more likely to say their providers understood and respected their cultural values and beliefs most or every time compared with those who had fewer visits with language-concordant providers (87% vs. 76%). While few LEP adults overall say their provider asked them about their work, housing situation or access to food or transportation during recent health care visits, those who had at least half of their visits with language concordant providers are more likely than those who had fewer visits with such providers to say this happened at least most of the time (29% vs. 15%).

Adults With LEP Who Have More Visits With Language-Concordant Providers Are More Likely To Say Providers Respect Their Values and Ask About Social Factors

Methodology

The Survey on Racism, Discrimination, and Health was designed and analyzed by researchers at KFF. The survey was conducted June 6 – August 14, 2023, online and by telephone among a nationally representative sample of 6,292 U.S. adults in English (5,706), Spanish (520), Chinese (37), Korean (16), and Vietnamese (13).

The sample includes 5,073 adults who were reached through an address-based sample (ABS) and completed the survey online (4,529) or over the phone (544). An additional 1,219 adults were reached through a random digit dial telephone (RDD) sample of prepaid (pay-as-you-go) cell phone numbers. Marketing Systems Groups (MSG) provided both the ABS and RDD sample. All fieldwork was managed by SSRS of Glen Mills, PA; sampling design and weighting was done in collaboration with KFF.

Sampling strategy:

The project was designed to reach a large sample of Black adults, Hispanic adults, and Asian adults. To accomplish this, the sampling strategy included increased efforts to reach geographic areas with larger shares of the population having less than a college education and larger shares of households with a Hispanic, Black, and/or Asian resident within the ABS sample, and geographic areas with larger shares of Hispanic and non-Hispanic Black adults within the RDD sample.

The ABS was divided into areas (strata) based on the share of households with a Hispanic, Black, and/or Asian resident, as well as the share of the population with a college degree within each Census block group. To increase the likelihood of reaching the populations of interest, strata with higher incidence of Hispanic, Black, and Asian households, and with lower educational attainment, were oversampled in the ABS design. The RDD sample of prepaid (pay-as-you-go) cell phone numbers was disproportionately stratified to reach Hispanic and non-Hispanic Black respondents based on incidence of these populations at the county level.

Incentives:

Respondents received a $10 incentive for their participation, with interviews completed by phone receiving a mailed check and web respondents receiving a $10 electronic gift card incentive to their choice of six companies, a Visa gift card, or a CharityChoice donation.

Community and expert input:

Input from organizations and individuals that directly serve or have expertise in issues facing historically underserved or marginalized populations helped shape the questionnaire and reporting. These community representatives were offered a modest honorarium for their time and effort to provide input, attend meetings, and offer their expertise on dissemination of findings.

Translation:

After the content of the questionnaire was largely finalized, SSRS conducted a telephone pretest in English and adjustments were made to the questionnaire. Following the English pretest, Cetra Language Solutions translated the survey instrument from English into the four languages outlined above and checked the CATI and web programming to ensure translations were properly overlayed. Additionally, phone interviewing supervisors fluent in each language reviewed the final programmed survey to ensure all translations were accurate and reflected the same meaning as the English version of the survey.

Data quality check:

A series of data quality checks were run on the final data. The online questionnaire included two questions designed to establish that respondents were paying attention and cases were monitored for data quality including item non-response, mean length, and straight lining. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, 4 cases were removed.

Weighting:

The combined cell phone and ABS samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). The combined sample was divided into five groups based on race or ethnicity (White alone, non-Hispanic; Hispanic; Black alone, non-Hispanic; Asian alone, non-Hispanic; and other race or multi-racial, non-Hispanic) and each group was weighted separately. Within each group, the weighting parameters included sex, age, education, nativity, citizenship, census region, urbanicity, and household tenure. For the Hispanic and Asian groups, English language proficiency and country of origin were also included in the weighting adjustment. The general population weight combines the five groups and weights them proportionally to their population size.

A separate weight was created for the American Indian and Alaska Native (AIAN) sample using data from the Census Bureau’s 2022 American Community Survey (ACS). The weighting parameters for this group included sex, education, race and ethnicity, region, nativity, and citizenship. For more information on the AIAN sample including some limitations, adjustments made to make the sample more representative, and considerations for data interpretation, see Appendix 2.

All weights also take into account differences in the probability of selection for each sample type (ABS and prepaid cell phone). This includes adjustment for the sample design and geographic stratification of the samples, and within household probability of selection.

The margin of sampling error including the design effect for the full sample is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. Appendix 1 provides more detail on how race and ethnicity was measured in this survey and the coding of the analysis groups. For results based on other subgroups, the margin of sampling error may be higher. All tests of statistical significance account for the design effect due to weighting. Dependent t-tests were used to test for statistical significance across the overlapping groups.

Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

GroupN (unweighted)M.O.S.E.
Total6,292± 2 percentage points
Race/Ethnicity
White, non-Hispanic (alone)1,725± 3 percentage points
Black (alone or in combination)1,991± 3 percentage points
Hispanic1,775± 3 percentage points
Asian (alone or in combination)693± 5 percentage points
American Indian and Alaska Native (alone or in combination)267± 8 percentage points

 

Endnotes

  1. The KFF Survey on Racism, Discrimination, and Health was conducted in English plus four additional languages: Spanish, Chinese, Vietnamese and Korean. While it is not comprehensive of all adults with LEP, these languages make up about three fourths of the LEP population in the U.S. The survey results may somewhat overrepresent Spanish speakers, who make up 62% of the overall U.S. LEP population but 82% of respondents with LEP from the survey. ↩︎
  2. In this report Adults with Limited English Proficiency (LEP) are adults who responded the survey in a language other than English and self-identified as speaking English less than u201cvery well.u201d English-proficient adults are those who responded the survey in English or responded in another language and self-identified as speaking English u201cvery well.u201d ↩︎
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The Implications of the Public’s Pre-existing Condition Amnesia

Published: May 16, 2024

In this JAMA Health Forum column, KFF’s Executive Vice President for Health Policy Larry Levitt discusses waning awareness of the Affordable Care Act’s provisions protecting people with pre-existing conditions and examines the Republican Study Committee’s budget proposal, which proposes to repeal the provisions.

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Where ACA Marketplace Enrollment is Growing the Fastest, and Why

Published: May 16, 2024

In 2024, Affordable Care Act (ACA) Marketplace enrollment hit a new record high, reaching over 21 million people, almost double the 11 million people enrolled in 2020. This growth can be largely attributed to enhanced subsidies made available by the American Rescue Plan Act (ARPA) in 2021 and renewed under the 2022 Inflation Reduction Act (IRA). These enhanced subsidies significantly reduced premium payments across the board for ACA Marketplace enrollees – including providing 100% premium subsidies for the lowest-income enrollees – and made some middle-income people who had previously been priced out of coverage newly eligible for financial assistance.

2024 ACA Open Enrollment Hits a New Record

Although the Inflation Reduction Act’s enhanced subsidies are available nationwide, some states have seen faster growth than others. In 15 states, ACA Marketplace enrollment has more than doubled since 2020 (Figure 2). One of these states is Texas, where ACA enrollment has more than tripled since 2020. Meanwhile, 3 states’ Marketplaces have seen enrollment fall since 2020.

In 15 States, Affordable Care Act (ACA) Marketplace Enrollment More than Doubled from 2020 to 2024

The five states with the fastest growth in Marketplace enrollment since 2020 – Texas (212%), Mississippi (190%), Georgia (181%), Tennessee (177%), and South Carolina (167%) – have certain characteristics in common: They all started off with high uninsured rates before the enhanced subsidies rolled out, they have not expanded Medicaid under the ACA, and they all use the Healthcare.gov enrollment platform.

It is difficult to disentangle the effect of each of these factors (uninsured rate, Medicaid expansion, and enrollment platform), as they are correlated and closely connected to one another. Nonetheless, the data suggest that a large number of uninsured people in these southern states with high uninsured rates wanted health insurance coverage, and the recently enhanced subsidies have made it possible for them to afford that coverage. However, these subsidies are temporary and will expire at the end of 2025 if not renewed by Congress.

Uninsured Rate

When considering the varying growth rates of Marketplace enrollment across states in recent years, it is important to keep in mind that states had different starting points before the enhanced subsidies in the ARPA and IRA were rolled out. The nonelderly uninsured rate in 2019 ranged from less than 5% in Massachusetts, the District of Columbia, and Hawaii to over 15% in Mississippi, Georgia, Florida, and Oklahoma, and over 20% in Texas. Generally speaking, states with higher uninsured rates in 2019 saw faster growth in ACA Marketplace enrollment from 2020 to 2024, while those with the lowest uninsured rates saw their market sizes generally grow less or even shrink a bit. On average, states that started out with nonelderly uninsured rates below 10 percent in 2019 saw an average of 31% growth in ACA Marketplace enrollment, while states with uninsured rates of 10 percent or more saw an average growth of 136% from 2020 to 2024.

Since 2020, ACA Marketplaces Have Generally Grown Faster in States that Started off with Higher Uninsured Rates

Medicaid Expansion

Another closely related factor that could explain why some states are seeing faster growth in their ACA markets is Medicaid expansion. On average, non-expansion states have seen their ACA Marketplaces grow by 152% since 2020, compared to 47% average growth in expansion states.

Affordable Care Act Marketplaces have Grown Faster in Medicaid Non-Expansion States

The Inflation Reduction Act subsidies bring premiums for ACA Marketplace silver plans down to as low as $0 per month for people with incomes between 100% and 150% of poverty. Meanwhile, in states that have expanded Medicaid, people with incomes up to 138% of poverty are eligible for Medicaid and are therefore ineligible to purchase ACA Marketplace plans. There are therefore relatively fewer people in Medicaid expansion states who would qualify for one of these “free” silver plans on the ACA Marketplaces. This could explain, in part, why there has been faster Marketplace growth in several non-expansion states. (With North Carolina recently expanding Medicaid, there are now 10 states, primarily in the South, that have chosen not to expand the program).

The unwinding of the pandemic-era Medicaid continuous enrollment policy, which led to millions of people losing Medicaid in 2023 after having their coverage maintained during the pandemic, likely contributed to the steeper increase in Marketplace enrollment during the 2024 open enrollment period. As states unwind the Medicaid continuous enrollment policy, these $0 premium, low-deductible ACA Marketplace plans may make the transition from Medicaid to Marketplace coverage easier, especially for people with incomes just above the poverty level in non-expansion states.

Enrollment Platforms

Growth in ACA Marketplace enrollment in recent years also correlates with enrollment platforms. The 23 states with the fastest growth in ACA Marketplace enrollment from 2020-2024 all use the Healthcare.gov enrollment platform. States using Healthcare.gov saw a weighted average growth of 126% in ACA Marketplace enrollment from 2020 to 2024, compared to 22% growth in states using state-run enrollment websites. All 10 states that have not expanded Medicaid use the Healthcare.gov platform.

States with the Most Growth in ACA Signups use the HealthCare.gov Platform

Another difference is that only Healthcare.gov states have Enhanced Direct Enrollment, which allows health plans and insurance brokers to directly enroll and provide customer service to enrollees throughout the year without the consumer needing to visit the Marketplace website (Healthcare.gov). In recent years, brokers have played a growing role in assisting Marketplace consumers.

However, states that use their own enrollment websites also had different starting points in 2020, ahead of the enhanced subsidies passing in 2021. Some state-based Marketplaces were already using state funds to offer additional health insurance subsidies beyond those offered by the federal government. Additionally, several states with their own Marketplaces had long embraced the ACA and have directed state resources toward outreach and marketing efforts for a decade. By contrast, states that rely on Healthcare.gov had significant cuts to outreach and marketing budgets during the Trump administration, with those investments renewed in 2021 under the Biden Administration.

Marketplace Plan Selections, 2020 and 2024
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News Release

States with the Fastest Recent Growth in ACA Marketplace Coverage Started with High Uninsured Rates

Published: May 16, 2024

The states with the fastest recent growth in ACA Marketplace signups also had among the highest uninsured rates previously, as enhanced subsidies helped to make coverage more affordable for many consumers, particularly in southern states that did not expand their Medicaid programs to cover low-income adults, a new KFF analysis finds. The enhanced premium subsidies were first provided in the American Rescue Plan Act in 2021 and then extended through 2025 in the Inflation Reduction Act.

Marketplace enrollment has more than doubled in 15 states since 2020, including in Texas, where signups more than tripled (growing by 212%). On average, states that started out with nonelderly uninsured rates below 10% in 2019 saw an average of 31% growth in ACA Marketplace enrollment, while states with uninsured rates of 10% or more saw an average growth of 136% from 2020 to 2024.None of the five states with the largest growth in recent ACA marketplace enrollment – Texas, Mississippi, Georgia, Tennessee, and South Carolina – have expanded Medicaid. 

States that have not expanded their Medicaid programs under the ACA have seen their Marketplaces grow by 152% on average since 2020, compared to 47% average growth in expansion states. This reflects, in part, that many low-income people who would be eligible for Medicaid if they lived in expansion states are instead able to sign up for Marketplace coverage in non-expansion states without having to pay a premium. Growth in ACA Marketplace enrollment in recent years also correlates with the type of enrollment platform, with states using Healthcare.gov seeing ACA Marketplace enrollment growing by 126% on average from 2020 to 2024, compared to 22% growth in states using state-run enrollment websites. This difference in growth could be explained in part by states’ differing starting points. States that use their own platforms are more likely to have made earlier and more consistent investments in outreach and marketing, and some had state-funded subsidies before the federal government’s enhanced subsidies. Additionally, states using Healthcare.gov have an option for brokers to enroll Marketplace customers directly without visiting the exchange website, which could have helped boost enrollment in states using the federal platform. 

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Tammie Smith

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News Release

KFF Examines New Rule Giving LGBTQ+ People More Protections Against Discrimination in Health Care

Published: May 15, 2024

A long-awaited new rule recently finalized by the Biden Administration gives LGBTQ+ people more protections against discrimination when seeking health care and coverage from a range of programs and organizations, including Medicaid, Medicare, Health Insurance Marketplaces, many health insurance plans, and most hospitals and providers. The rule has been subject to a wave of litigation across the Obama, Trump, and Biden Administrations and the Biden Administration’s new rule reinstates protections eliminated by the Trump Administration.

In a new brief, KFF examines the rule and highlights two areas of interest— nondiscrimination protections for pregnancy related decisions, including abortion, and nondiscrimination protections for transgender people, including those related to gender affirming care. The brief also provides a side-by-side comparison of the Obama (2016), Trump (2020), and Biden Administration (2024) rules.

The revised regulations implement Section 1557 of the Affordable Care Act, which prohibits discrimination based on race, color, national origin, age, disability, or sex in covered health programs or activities. The Biden Administration’s interpretation of the ACA’s sex protections also offers protections based on sexual orientation and gender identity, among other considerations.

Beyond those for LGBTQ+ people, the rule also provides a range of other nondiscrimination protections, including those related to abortion; people with disabilities; people with limited English proficiency; and use of telehealth and patient care decision support tools, including clinical algorithms and AI. The rule also extends to include Medicare Part B for the first time.

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Mikhaila RIchards

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