During the three years of the pandemic, states maintained coverage for people enrolled in Medicaid. As a result of this continuous enrollment provision, the number of people enrolled in Medicaid increased. The result – in combination with enhanced premium subsidies in the Affordable Care Act marketplace – is that the number of people who were uninsured decreased and the uninsured rate dropped to historic lows. However, despite these improvements in coverage, 25.6 million nonelderly people remained uninsured in 2022 (Figure 1), and six in ten of the uninsured people are eligible for Medicaid (6.4 million or 25%) or subsidized plans (35%) in the Marketplace but are not enrolled in these programs. Among the remaining uninsured, 6% fall into the “coverage gap” because they live in one of the 10 states that have not adopted the Medicaid expansion. People in the coverage gap have incomes too high to qualify for Medicaid in their state, but too low (below 100% of the poverty level) to qualify for subsidies in the Marketplaces. States began the process of unwinding continuous enrollment in the spring/summer of 2023 and have disenrolled millions of people from Medicaid, likely increasing the number of people who are uninsured.

This issue brief examines the characteristics of the nonelderly uninsured population that is eligible for Medicaid or CHIP using the most recent available national survey data from 2022, which is before the end of Medicaid continuous enrollment, and the most recent eligibility levels for Medicaid (from 2023). Even with declines in the uninsured, the characteristics of the uninsured but eligible for Medicaid remained fairly stable from the prior year.

Who are the people who are uninsured and eligible for Medicaid and CHIP?

Among the 6.4 million nonelderly people who are uninsured and eligible for Medicaid or CHIP (referred to as people who are uninsured and eligible for the rest of this brief), most are adults. Two-thirds of people who are uninsured and eligible, 4.2 million, are adults and one-third, 2.2 million, are children (Figure 2). Adults include those eligible for the program through the Medicaid expansion and individuals who qualify under pre-ACA rules but are not enrolled.

Across all people who are uninsured and eligible, over six in ten are people of color and nearly seven in ten live in working families (Figure 2). Nonelderly Hispanic people account for 36.0% of those who are uninsured and eligible, and Black people account for another 13.9%. While just under three in ten (29.6%) of people who are uninsured and eligible are in families with no workers, over half (54.6%) are in families with one or more full-time workers. Both full- and part-time low-wage workers are less likely to report having an offer of coverage from their employer than higher wage workers, and among those with an offer of coverage, are more likely to report the coverage offered is too expensive.

Over three-quarters of the 6.4 million people who are uninsured and eligible (5.2 million people) reside in expansion states, which have more people living in them and have higher Medicaid income eligibility for adults than non-expansion states (Figure 2). The remaining 1.2 million people are in states that have not expanded Medicaid but are eligible for Medicaid or CHIP under traditional (not ACA expansion) pathways. Most of the people who are uninsured and eligible in expansion states are adults, while children make up the majority of uninsured and eligible people in non-expansion states (Figure 2). All states have opted to set eligibility thresholds for children in Medicaid and CHIP at higher levels, in most states above 200% of poverty. In Medicaid expansion states, eligibility for adults was expanded to 138% of poverty ($20,783 for an individual and $35,632 for a family of three in 2024) and extended to adults without children. In non-expansion states, eligibility is limited for adults, often to below half of the federal poverty level, and generally only available for parents of dependent children. The differences in eligibility for adults across expansion and non-expansion states drives the variation in the shares of children and adults who are uninsured but eligible for Medicaid and CHIP for these states.

What are key issues to watch?

Medicaid continuous enrollment contributed to a decline in the number of people uninsured overall as well as the number of uninsured individuals who are eligible for Medicaid but not enrolled. However, since the end of continuous enrollment on March 31, 2023, states have disenrolled millions of people. Although national survey data that will show changes in coverage is lagged, the unwinding of continuous enrollment is expected to increase the number of people who are uninsured, including among those who are still eligible for Medicaid and those who are eligible for subsidies in the Marketplace. Some people who are disenrolled from Medicaid for procedural or paperwork reasons, even though they are still eligible for Medicaid, may struggle to re-enroll and may remain uninsured. Even as the number of people who are uninsured increases, the characteristics of those who are eligible for Medicaid but uninsured may remain relatively stable. Understanding these characteristics can help inform outreach efforts as well as policy changes that can mitigate coverage losses by making it easier for people who are eligible to obtain or retain Medicaid coverage.

Medicare provides health insurance coverage to 66 million adults, including 59 million adults ages 65 and older and more than 7 million adults under age 65 with disabilities. While the vast majority (91%) of Medicare beneficiaries give their Medicare coverage an overall positive rating, health care cost-related problems are not uncommon. Medicare beneficiaries contribute to the cost of their health care coverage through monthly premium payments, deductibles, and other cost-sharing requirements. Additionally, people on Medicare may face additional premiums for Medicare Part D prescription drug coverage and supplemental insurance. Further, there is no limit on out-of-pocket spending for beneficiaries in traditional Medicare, and beneficiaries often incur out-of-pocket costs for services not covered under traditional Medicare, such as dental, hearing, and vision services. Medicare Advantage plans have a cap on out-of-pocket costs and typically offer reduced cost-sharing for no premium, but enrollees can still have substantial expenses.

In 2022, the Consumer Price Index (CPI) for all Urban Consumers, a closely tracked measure of price inflation, increased to its highest annual rate since 1981, which translated to higher costs for housing, food, transportation, and other household expenditures, including health care costs. The inflation rate has come down since then, but prices for many household expenses are still substantially higher than they were previously. In this analysis, we assess the financial burden of health care spending among households where all members are covered by Medicare (referred to as Medicare households) compared to households where no members are covered by Medicare (referred to as non-Medicare households), based on data from the 2022 Consumer Expenditure Survey. We also assess trends in household spending and the financial burden of health care spending over the 10-year period from 2013 to 2022. (See Methods for details on the analysis.)

The health spending burden was twice as large among Medicare households than non-Medicare households in 2022

Average health-related expenses accounted for 13.6% of Medicare households’ total spending in 2022 compared to 6.5% for non-Medicare households.

Medicare households spent more on health care than non-Medicare households in 2022, both as an annual dollar amount and as a share of total household spending. Medicare households spent an average of $7,000 on health care, accounting for 13.6% of their total household spending ($51,800), while non-Medicare households spent $4,900 on their health care, accounting for 6.5% of their total household spending ($74,100) (Figure 1). Health care expenses include health insurance premiums, medical services (e.g., hospital and physician services), prescription drugs, and medical supplies (e.g., crutches, eyeglasses, hearing aids).

The larger burden of health care spending among Medicare households than non-Medicare households is a function of both lower average total household spending for Medicare households than non-Medicare households and higher health care use, which results in higher health care spending by Medicare households.

Across all household spending categories, housing accounted for the largest share of total spending for both Medicare and non-Medicare households (35.3% for Medicare households and 32.5% for non-Medicare households). Across other major categories of household spending – transportation, food, and other expenses such as education and clothing – Medicare households devoted a smaller share of their household spending (and less in dollar terms) to these items than non-Medicare households. This may be a function of both smaller average family sizes in Medicare households than non-Medicare households (1.4 vs. 2.6 people), as well as lower median household income ($31,700 vs $76,600).

In 2022, nearly 3 in 10 Medicare households spent 20% or more of their total household spending on health-related expenses, compared to 7% of non-Medicare households

Consistent with the higher average health care spending burden among Medicare households compared to non-Medicare households, a larger share of Medicare households than non-Medicare households spent 20% or more of their total household spending on health-related expenses than non-Medicare households – nearly 3 in 10 (29%) Medicare households versus 7% of non-Medicare households. Nearly three out of four Medicare households (74%) spent 10% percent or more of their total household spending on health expenses, compared to a quarter (25%) of non-Medicare households (Figure 2).

Health care spending by Medicare households increased by 53% between 2013 and 2022, but health care as a share of total household spending changed very little over these years

In 2022, Medicare households spent an average of $7,000 on health care—$2,400 or 53% higher than the amount spent on health care in 2013 ($4,600) (Figure 3). With total household spending by Medicare households growing at nearly the same rate as the growth in health care spending over these years, health care as a share of total household spending was nearly the same in 2022 (13.6%) as in 2013 (13.5%).

Similarly, non-Medicare households also spent more on health care in 2022 ($4,900) than in 2013 ($2,800), a 71% ($2,100) increase. Health care as a share of total household spending for non-Medicare households was somewhat higher in 2022 (6.5%) than in 2013 (5.4%).

Focusing on household spending trends between 2019 and 2022 shows the dual effects of the COVID-19 pandemic and price inflation.

Between 2019 and 2020, spending by Medicare households on food and transportation fell, likely reflecting stay-at-home policies established at the outset of the COVID-19 pandemic, and total household spending declined somewhat (Figure 4). By contrast, between 2021 and 2022, total household spending increased substantially, reflecting increases in all categories of household spending, as price inflation hit its highest level since 1981 in 2022. This was true for both Medicare households and non-Medicare households.

Discussion

The health care spending burden was twice as large for Medicare households than for non-Medicare households in 2022, measured by average health care spending as a share of total household spending, and a larger share of Medicare households spent at least 20% of their household budgets on health care than non-Medicare households. Of note, this analysis underestimates the health care spending burden for households that incur long-term care facility costs because the Consumer Expenditure Survey does not include people who reside in facilities. This exclusion is more likely to affect the spending burden estimates for Medicare households than non-Medicare households since spending on long-term care facilities is a significant share of average out-of-pocket health care costs for people with Medicare.

With health care use increasing with age and with most Medicare beneficiaries living on relatively low incomes and modest financial assets to draw upon in retirement, it’s not unexpected that health care is a bigger cost burden for Medicare households. This cost burden has important implications for policy debates, including the level of cost-sharing and premiums in Medicare. Policies aimed at improving financial protections for Medicare beneficiaries have been proposed in recent years. The Inflation Reduction Act of 2022 includes several provisions that lower prescription drug costs for people with Medicare, including a cap on Medicare beneficiaries’ out-of-pocket spending under the Medicare Part D benefit; a limit on insulin cost sharing to $35 a month in Medicare Part B and Part D; and expanded eligibility for full Part D Low-Income Subsidies. Policy makers have also considered other proposals that would improve the affordability of health care for Medicare beneficiaries, such as expanding income eligibility thresholds for the Medicare Savings Programs to enable more people to qualify for these financial supports, and adding an out-of-pocket cap on cost sharing for benefits covered under traditional Medicare. Adopting such changes, however, would require additional federal spending.

As rates of childhood vaccination decline and with measles on the rise again, a KFF Health Misinformation Tracking Poll, fielded in late February, examines the extent to which adults have heard and believe misinformation about the measles vaccine. The poll also examines the public’s views of the U.S. government and social media companies’ role in moderating false health claims online.

While most of the public—including parents—haven’t heard misinformation about the measles vaccine, many are uncertain about the validity of one specific false claim. About one in five adults (18%, including 19% of parents of children under age 18) say they have heard or read the claim, “Getting the measles vaccine is more dangerous than becoming infected with measles.”

A relatively small share leans towards believing the claim is true. Regardless of whether they have heard the claim, a fifth of adults (19%), including one quarter of parents (25%), say the claim is “definitely” or “probably” true. Six percent of U.S. adults—including about one in ten (9%) parents—say they have heard the claim and think it is probably or definitely true.

Across partisans, levels of educational attainment, and race and ethnicity, fewer than five percent of adults say that the claim is “definitely true,” meaning that there are few ardent believers in this piece of misinformation. However, independents (37%) and Republicans (21%) are less likely than Democrats (59%) to be certain that the claim is “definitely false.” Those without a college degree (29%) are also less likely to say that the claim is false than those with a college degree (55%).

Large Shares Support Social Media Companies in Restricting Health Misinformation at the Expense of Certain Freedoms

Later this March, the Supreme Court will hear arguments in three important cases related to misinformation on social media that will have implications for how the U.S. government and social media companies interact with users and can moderate information.

Two-thirds (68%) of the public views the spread of health misinformation on social media as a bigger problem than censorship of speech on social media platforms (31%). This sentiment is in turn reflected in opinions about what kind of action social media companies should take to curb the spread of false health claims.

Large shares of the public support social media companies in tamping down on misinformation even at the expense of certain freedoms. About two-thirds (66%) of adults overall say, “Social media companies should restrict false health information, even if it limits people from freely publishing or accessing information,” while one-third instead say “People’s freedom to publish and access health information should be protected, even if it means false information can also be published.”

The public is more divided about whether the U.S. government should take action. Nearly six in ten adults overall (57%) say, “The U.S. government should require social media companies to take steps to restrict false health information, even if it limits people from freely publishing or accessing information,” while about four in ten (42%) say “People’s freedom to publish and access health information should be protected, even if it means false information can also be published.”

There are partisan divisions on both these questions, with Democrats more likely than independents or Republicans to favor both the government and social media companies taking action to restrict false health information. Notably, however, majorities of Democrats (82%), independents (57%), and Republicans (56%) say that social media companies should take steps to restrict health misinformation even if it limits certain freedoms.

The Health Misinformation Tracking Poll is part of a new KFF program area focused on identifying and monitoring health misinformation and trust in the United States, emphasizing communities that are most adversely affected by misinformation, including people of color, immigrants, and rural communities.

Designed and analyzed by public opinion researchers at KFF, the poll was conducted from February 20-28, 2024, online and by telephone among a nationally representative sample of 1,316 U.S. adults including 283 parents. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample and 7 percentage points for the sample of parents. For results based on other subgroups, the margin of sampling error may be higher.

About half (47%) of immigrant adults in the U.S. have limited English proficiency (LEP), meaning that they speak English less than very well. Immigrants with LEP come from diverse backgrounds and speak a variety of languages. The top five languages spoken by people with LEP include Spanish (63%), Chinese (7%), Vietnamese (3%), Arabic (2%), and Tagalog (2%), while the remaining roughly quarter (23%) of people with LEP speak other languages. Having LEP can impact individuals’ daily lives and access to health coverage and care. Below are five key facts about immigrants with LEP drawing on the 2023 KFF/LA Times Survey of Immigrants.

About half (53%) of immigrants with LEP say they have faced language barriers in a variety of interactions, including accessing health care.

About three in ten immigrants with LEP report that difficulty speaking or understanding English has ever made it hard for them to get health care services (31%), receive services in a store or restaurants (30%), or get or keep a job (29%) (Figure 1). A quarter say it has made it hard to apply for government financial assistance for food, housing, or health coverage, and about one in five (22%) cite difficulty reporting a crime or getting help from the police. These difficulties are more pronounced among lower income immigrants with LEP. Among immigrants who are parents with LEP (52% of all immigrant parents), about one in four (24%) report difficulties communicating with their child’s school.

Immigrants with LEP (21%) are twice as likely to be uninsured as immigrants who are English proficient (10%).

Immigrants with LEP are twice as likely as English proficient immigrants (defined as speaking English exclusively/very well) to be uninsured (21% vs 10%) (Figure 2), and parents with LEP are about three times as likely to say they have a child who is uninsured compared to English proficient immigrant parents (14% vs. 5%).This pattern reflects lower rates of private coverage among immigrants with LEP due to disproportionate employment in lower income jobs that are less likely to offer employer-based insurance. While Medicaid helps fill some of this gap, some may also face linguistic and other barriers to enrollment even if they are eligible for coverage.

Immigrants with LEP face greater barriers to accessing health care and report worse health compared to their English proficient counterparts.

Reflecting their higher uninsured rates and other barriers, immigrants with LEP are somewhat less likely than those who are English proficient to say they have a usual source of care other than the emergency room (77% vs 84%), have a trusted health care provider (68% vs. 80%) and to have seen a health care provider within the past year (74% vs. 80%). However, they are twice as likely as their English proficient immigrants to report fair or poor health status (28% vs. 14%). Community health centers (CHCs) play a particularly important role serving immigrants with LEP, with about four in ten (39%) saying that they usually rely on a CHC for care, reflecting CHCs’ role serving uninsured populations and their provision of linguistically and culturally appropriate services.

About half (55%) of immigrant workers with LEP report experiencing discrimination at work.

While immigrants with LEP are as likely as their English proficient peers to be employed (64% vs 67%), they are more likely to be in hourly jobs (60% vs. 45%) and less likely to receive a salary (21% vs 42%) (Figure 4). Reflecting these patterns, they are more likely to have lower incomes, with 55% having household incomes of less than $40,000 per year compared with 28% of English proficient immigrants. Half (55%) of immigrant workers with LEP report experiences with discrimination at work, such as being given fewer opportunities for advancement compared to people born in the U.S. doing the same job (38%), getting paid less (34%),not getting paid for all hours they worked (25%), being given undesirable work shifts or having less control over their hours than people born in the U.S. doing the same work (21%), or being harassed or threatened by someone at their work because they are an immigrant (14%).

About six in ten immigrants with LEP say they lack sufficient information about U.S. immigration policy (58%) and are unsure about public charge rules (62%).

About six in ten immigrants with LEP (58%) say they do not have enough information about U.S. immigration policy to understand how it affects them and their family compared with 34% of English proficient immigrants (Figure 5). Immigrants with LEP primarily get their information on immigration policy from a search engine such as Google (30%), a U.S. government website (26%), or an attorney or other professional (24%). They are less likely than English proficient immigrants to seek information from an internet search engine and more likely to rely on an attorney or other professional and other sources of information such as news media, social media, and family and friends. Information gaps among immigrants with LEP extend to public charge rules, with 62% saying they are unsure about whether using government programs to help pay for health care, housing, or food will decrease their chances of being approved for a green card compared with 55% of those who are English proficient, and another 17% incorrectly believing this to be the case.

KFF takes a new look at the continued impact of the Hyde Amendment, the federal ban on payment for abortion services, in the wake of the Supreme Court’s Dobbs decision. At a moment when all eyes are on states that have banned abortion, the Hyde Amendment remains a barrier to abortion care for people with low incomes in states where abortion is legal but the state restricts Medicaid coverage to the narrow exceptions allowed under Hyde.

Today, the policy limits abortion coverage in 19 states and the District of Columbia where abortion isn’t banned. The policy potentially affects 5.5 million women ages 15 to 49 who reside in those states and are covered by Medicaid.

Since 1977, the Hyde Amendment has banned the use of federal funds for abortion, allowing exceptions to pay for terminating pregnancies that endanger the life of the pregnant person or that result from rape or incest.  This policy has limited abortion coverage for millions of pregnant people on Medicaid, as well others who rely on federal programs such as Medicare, TRICARE, and the federal Employee Health Benefit Program for their coverage.

This longstanding federal funding ban has had a disproportionate effect on women with low incomes and women of color who are covered by Medicaid at higher rates and are more likely to seek abortion care because of persistent systemic barriers to care and contraceptive access. Some states choose to pay for abortions for their Medicaid enrollees in other instances but use their own state revenues, not federal funds, to cover the service.

For more information about the federal programs affected by the Hyde Amendment, the impact of the law on access to abortion services, and the potential effect if the law were to be repealed, check out the brief, “The Hyde Amendment and Coverage for Abortion Services Under Medicaid in the Post-Roe Era.”

Adult children of immigrants make up a disproportionately large share of physicians, surgeons and other health care practitioners in the U.S. — just one reflection of their comparatively high employment, educational attainment and income levels, according to a new KFF analysis.

The analysis of 2023 Current Population Survey data shows that U.S.-born nonelderly adults whose parents were both born outside the U.S. comprise 13% of physicians, surgeons, and other health care practitioners. That amounts to more than twice their share of the working age population (6%). 

The data show that the adult children of immigrants have higher educational attainment compared to their peers with U.S.-born parents. Forty-five percent of nonelderly adult children of immigrants hold a bachelor’s degree or higher, compared to 40% of adults with at least one U.S.-born parent. 

Adult children of immigrants also are somewhat more likely to have higher incomes, with 39% living in households with an annual income of $90,000 or more. In comparison, about one in three (36%) of nonelderly adults with at least one U.S.-born parent live in higher income households.Other key findings include: 

• Three in four (76%) nonelderly adult children of immigrants are employed, accounting for 6% of the nonelderly adult workforce, similar to their share of the nonelderly adult population (6%). The rate is higher among adult children of immigrants between the ages of 25 and 64, who are less likely to be students, with 81% of this group working compared to 78% of their peers with at least one U.S.-born parent. 
•  Nonelderly adult children of immigrants are less likely than those with U.S.-born parents to have private health coverage (67% vs. 76%) and more likely to be uninsured (13% vs. 8%). Their higher uninsured rate may reflect that they are more likely to be working in some industries like construction, food services, and transportation, which may be less likely to offer health coverage.

The full analysis, “The Role of Adult Children of Immigrants in the U.S. Health Care Workforce”, is available at kff.org.

Introduction

Immigrants and their children form a growing share of the U.S. population and make important contributions to the country’s culture, economy, and workforce. One of the major reasons why immigrants come to the U.S. is for improved educational and employment opportunities for their children. Many children of immigrants realize their parents’ dreams by attaining high levels of education and jobs that allow for an improved quality of life. Adult children of immigrants also play an important role in supporting the U.S. workforce and economy, particularly in certain sectors, including health care. This brief examines key characteristics of nonelderly adult children of immigrants and their role in the workforce, including the health care workforce, based on KFF analysis of 2023 Current Population Survey data (see Methods for details). All differences described in the text are statistically significant at p<0.05. Key takeaways include the following:

• Nonelderly adult children of immigrants are more likely than those with U.S.-born parents to be under age 35 and to be Hispanic or Asian. Six in ten (62%) nonelderly adult children of immigrants are under age 35 and three-quarters are Hispanic (55%) or Asian (22%). In comparison, about four in ten (37%) of nonelderly adults with at least one U.S.-born parent are under 35 years and one in ten is Hispanic (9%) or Asian (1%). About three in ten (28%) nonelderly adults who are immigrants themselves are under 35 years and three-quarters are Hispanic (49%) or Asian (25%).
• Nonelderly adult children of immigrants have somewhat higher educational attainment compared to their peers with U.S.-born parents and immigrant adults. Among those ages 25 to 64 (who are less likely to be students), over four in ten (45%) adult children of immigrants have a bachelor’s degree or higher compared with 40% of those with at least one U.S.-born parent and 38% of immigrant adults.
• About three-quarters (76%) of nonelderly adult children of immigrants and nonelderly adult immigrants (75%) are working and they make outsized contributions to the health care workforce. In particular, adult children of immigrants make up twice the share of physicians, surgeons, and other health care practitioners compared with their share of the population (13% vs. 6%). Immigrant adults also make up a larger share of physicians, surgeons, and other health care practitioners than they do of the population (23% vs. 19%) and play a particularly large role as direct care workers in long-term care settings, accounting for almost three in ten (28%) of these workers. In contrast, nonelderly adults with at least one U.S.-born parent make up a smaller share of physicians, surgeons, and other health care practitioners as well direct care workers in long-term care relative to their share of the population.
• Four in ten (39%) nonelderly adult children of immigrants live in households with an annual income of $90,000 or more and most (67%) have private health coverage. Similarly, about one in three (36%) of nonelderly adults with at least one U.S.-born parent and a quarter (25%) of nonelderly adult immigrants have annual household incomes of $90,000 or more. However, adult children of immigrants are less likely than adult children of U.S.-born parents to have private health coverage (67% vs. 76%) and more likely to be uninsured (13% vs. 8%), although they are more likely than immigrant adults to have coverage. Their higher uninsured rates relative to their peers with at least one U.S.-born parent may reflect that they are more likely to be employed in construction, food services, or transportation occupations, which may be less likely to offer employer-sponsored coverage.

These data suggest that proposals to limit workforce participation of immigrants or to end birthright citizenship for the children of some immigrants may adversely impact the U.S. workforce and economy. A reduction in the population of first- and second-generation immigrants may increase workforce shortages. The current health care workforce shortage in particular, which is projected to continue across professions, including allied health, long-term support services, behavioral health, and specialty physicians, may be exacerbated by such limitations given the disproportionate roles of both adult children of immigrants as well as immigrant adults in various health care occupations and industries. Worsening shortages could have negative effects on the nation’s health and well-being as well as the economy.

Background

In addition to the 45.5 million immigrants residing in the U.S. as of 2023, there are over 25.6 million U.S.-born individuals residing in the country who have immigrant parents (both parents born outside the U.S.), half of whom are nonelderly adults ages 19 to 64.¹  Immigrants and their adult children make up a growing share of the population and play an important role in the nation’s communities, workforce, and economy. Other research has shown that adult children of immigrants have higher levels of educational attainment and work in higher-earning professions than their parents. Analysis further shows that children of immigrants contribute more in taxes on average than their parents or the rest of the U.S.-born population, and their fiscal contributions exceed their costs associated with health care, education, and other social services. Moreover, as older generations exit the workforce, immigrants and their U.S.-born children have been the primary drivers of workforce growth, accounting for 83% of the growth in the U.S. labor force between 2010 and 2018.

At the same time, immigration remains a hot-button political issue in the U.S. and there is pervasive anti-immigrant rhetoric. A few states, like Florida, recently passed laws that seek to limit immigrants’ ability to participate in the workforce, and, at the national level, presidential candidates have made recent proposals to end or limit birthright citizenship, a right guaranteed under the 14^th amendment of the U.S. Constitution for children born in the U.S. regardless of their parents’ immigration status. Such proposals, which are intended to deter immigration, would not only impact immigrants’ and their children’s access to health care but could have broader ramifications for the nation’s workforce and economy, potentially exacerbating existing worker shortages, including in health care.

This brief analyzes data from the 2023 Current Population Survey Annual Social and Economic Supplement (CPS-ASEC) to present demographic, employment, and socioeconomic characteristics of nonelderly adults 19 to 64 years born in the U.S. to immigrant parents (“adult children of immigrant parents”) (defined as having both parents born outside the U.S) and how they compare to “adult children of U.S.-born parents” (defined as having at least one parent born in the U.S.) and immigrant adults (see Methods for more details).

Demographic Characteristics

Adult children of immigrants are more likely to be younger (under 35 years) and more likely to be Hispanic or Asian than adult children of U.S.-born parents. Six in ten (62%) adult children of immigrants are between 19 and 34 years compared to 37% with at least one U.S.-born parent and 28% of immigrant adults (Figure 1). In addition, almost three-quarters of adult children of immigrants (77%) and immigrant adults (74%) are Hispanic or Asian compared to one in ten (10%) with at least one U.S.-born parent (Figure 2).

Adult children of immigrants have somewhat higher educational attainment levels compared to their peers with U.S.-born parents and immigrant adults. Among those between the ages of 25 and 64 years (who are more likely to have completed school), over four in ten (45%) of adult children of immigrants have a bachelor’s degree or higher compared with 40% of those with at least one U.S.-born parent and 38% of immigrant adults (Figure 3).

Employment Characteristics

Three in four (76%), or nearly 8.7 million adult children of immigrants are employed, accounting for 6% of the nonelderly adult workforce, which is similar to their share of the nonelderly adult population (6%). Immigrants make up about one in five of the nonelderly adult workforce and population, while the remaining three-quarters of the nonelderly workforce and population are comprised of adults with at least one U.S.-born parent.

Employment rates for adult children of immigrants are similar to their counterparts with at least one U.S.-born parent and immigrant adults with roughly three in four employed, although among those ages 25 to 64, they are higher for adult children of immigrants. Among nonelderly adults between ages 25 to 64 (who are less likely to be students), about eight in ten (81%) adult children of immigrants are employed compared with 78% of their peers with at least one U.S.-born parent and 76% of immigrant adults in this age group.

The top five industries in which adult children of immigrants are employed include health care and social assistance; retail trade; educational services; professional, scientific, and technical;  and construction industries (Figure 5). Industry patterns for adult children of immigrants and their counterparts with U.S.-born parents are largely similar, with significant shares working in health care and social assistance (15% and 14%), retail trade (12% and 11%), professional, scientific, and technical industries (9% and 8%), educational services (9% and 10%), and in construction (7% for both). While significant shares of immigrant adults also are employed in health care and social assistance (12%) and professional, scientific, and technical industries (9%), their rates are lower, and over one in ten work in construction (11%). Significant shares of immigrant adults also are employed in food service (8%) and transportation (7%) industries.

Role in the Health Care Workforce

Adult children of immigrants and immigrant adults account for larger shares of physicians, surgeons, and other practitioners relative to their share of the nonelderly population. Specifically, adult children of immigrants make-up 13% of physicians, surgeons, and other practitioners, over twice their share of the nonelderly population (6%), and immigrant adults account for about a quarter (23%) of people in these occupations compared with 19% of the nonelderly population (Figure 6). (See Methods for details on health care occupation groupings.) Immigrant adults also play a particularly large role in the long-term care (LTC) workforce, making up almost three in ten (28%) of direct care workers in LTC settings, including registered nurses, licensed practical nurses, certified nursing assistants, home health aides, and personal care aides working in nursing homes, residential care facilities, or home health services. Reflecting this role, research has found that increased immigration is associated with improved staffing levels at U.S. nursing homes and consequently leads to improved outcomes for patients. On the other hand, adult children of at least one U.S.-born parent make up a smaller share of physicians, surgeons, and other practitioners as well as direct care workers in LTC than they do of the population (64% and 66% vs. 75%).

Income and Health Coverage

Adult children of immigrants attain greater upward mobility than their parents and have somewhat higher household incomes than immigrant adults as well as adult children of U.S.-born parents. Reflecting their higher rates of educational attainment and employment patterns, four in ten (39%) nonelderly adult children of immigrants live in households with an annual income of $90,000 or more compared with about one in three (36%) nonelderly adult children of U.S.-born parents and a quarter (25%) of nonelderly adult immigrants (Figure 7).

Most adult children of immigrants and immigrant adults have private health coverage, but they are more likely than adult children of U.S.-born parents to be uninsured (Figure 8). Despite high rates of employment and higher incomes, adult children of immigrants are less likely than adult children of U.S.-born parents to have private health coverage (67% vs. 76%) and are more likely to have Medicaid or other public coverage (20% vs. 16%) or to be uninsured (13% vs. 8%). However, they are more likely than immigrant adults to have private coverage (67% vs. 58%) and less likely to be uninsured (13% vs. 23%). While many adult children of immigrants work in health care and other professional occupations, they are more likely than those with at least one U.S. born parent to be in construction, food services, or transportation occupations, which may be less likely to offer employer-sponsored coverage. The higher uninsured rates among immigrant adults also reflect eligibility restrictions for federally funded coverage options, including Medicaid. Given their higher uninsured rates, immigrants and adult children of immigrants likely face increased barriers to accessing care and are at increased financial risk for health care costs.

1. KFF analysis of 2023 Current Population Survey Annual Social and Economic Supplement (CPS-ASEC). ↩︎

President Biden released his FY 2025 budget request on March 11, 2024. The President’s fourth and final budget request of his first term builds on past efforts to address the domestic HIV response, including by proposing slight funding increases for the “Ending the HIV Epidemic” (EHE) initiative and the Housing Opportunities for People with AIDS (HOPWA) Program. In addition, this is the third year the budget proposes a new mandatory HIV prevention program aimed at expanding the use of pre-exposure prophylaxis (PrEP), a medication that prevents HIV for those at higher risk.

The request also includes discretionary funding levels for key programs aimed at addressing the domestic HIV epidemic, including at the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS and Health Center Programs, the National Institutes of Health (NIH), the Dept. of Housing, Urban Development’s HOPWA Program, the Minority AIDS Initiative, and the Indian Health Service (IHS). It also marks the fifth year of budget requests for the EHE. (Not included here are funding levels through mandatory accounts, including Medicaid, Medicare, Social Security Insurance (SSI), and Social Security Disability Insurance (SSDI), which make up the majority of HIV spending by the federal government.)

As the FY 2024 budget has not yet been approved by Congress, comparisons are made to the FY 2023 level, when possible. An overall request total for discretionary HIV funding is not yet available as we await the domestic HIV funding level from NIH. The funding request for the EHE initiative totals $593.25 million, $20 million (3.5%) over the FY 2023 enacted level.

Key budget highlights are as follows.

CDC – HIV prevention

• The FY 2025 funding request for domestic HIV prevention at the CDC, which accounts for almost all federal funding for domestic HIV prevention, totals $1.0 billion which is the same level as the FY 2023 enacted amount.

HRSA – Ryan White and Health Center HIV Funding

• The Ryan White HIV/AIDS Program, the nation’s safety net for HIV care and treatment, receives $2.6 billion in the FY 2025 request, a $10 million (0.4%) increase over the FY 2023 enacted level. The small increase is attributed to EHE activities; the EHE receives $175 million in the request, an increase of $10 million (6.1%) over the FY 2023 enacted level.
• The FY 2025 budget request also includes $157.25 million in HIV funding for the Health Center Program at HRSA, all of which is for the EHE initiative, and is the same amount as the FY 2023 enacted level.

NIH – Domestic HIV Research

• The National Institutes of Health (NIH) carries out almost all federally funded HIV research activities. The domestic share of HIV funding is not yet known. The FY 2023 enacted level for domestic HIV research at NIH was $2.7 billion. (This line will be updated with FY 2025 request level, when possible.)
• Included in the overall HIV funding at NIH is funding for the EHE. The agency received $26 million in EHE funding in the request which is the same as the FY 2023 enacted level.

Indian Health Service (IHS)

• The FY 2024 budget request includes $15 million for EHE activities at the Indian Health Service (IHS). This is a $10 million, or 200% increase, over the FY 2023 enacted level of $5 million.

Housing Opportunities for People with AIDS (HOPWA)

• HOPWA is a program of the Department of Housing and Urban Development which provides housing assistance and supportive services to low-income people with HIV facing housing insecurity. The FY 2023 budget request includes $505 million, a $6 million (1%) increase over the FY 2023 enacted level.

PrEP Access through Medicaid and CHIP

• The budget creates a proposal which would require state Medicaid and CHIP programs to cover PrEP and associated laboratory services without cost-sharing for beneficiaries. It also “places guardrails on utilization management practices like prior authorization and step therapy.”

Mandatory PrEP Program

• For the third year in a row, the Budget proposes to repropose $9.8 billion over 10 years for a new mandatory Pre-Exposure Prophylaxis (PrEP) Delivery Program to End the HIV Epidemic in the United States (“PrEP Delivery Program”). The program would aim to “provide PrEP and associated services at no cost to uninsured and underinsured individuals and expand the number of providers serving underserved communities.”

The tables below compare federal funding levels for domestic HIV, where specified, in the FY 2025 request to the FY 2023 enacted levels. (As noted, FY24 funding levels are yet available for comparison.) Funding for the “Ending the HIV” Initiative is included in the overall table (Table 1) and in a dedicated table (Table 2). Funding for the new PrEP program is not included below as the following tables include discretionary funding only.

Key Documents:

• White House Budget Resources 
• HHS Budget Justification
• CDC Congressional Budget Justification
• HRSA Congressional Budget Justification 
• NIH Congressional Budget Justification 
• HUD Congressional Budget Justification
• IHS Congressional Budget Justification