Updated February 20, 2025, to correct the average deductible amount for standalone dental plans offered on the Marketplace in 2023.The 2023 KFF Consumer Survey of Consumer Experiences with Health Insurance finds cost barriers to adult dental care across coverage types. Conducted in February and March of 2023, the survey includes a nationally representative sample of 3,605 U.S. adults who have health insurance. This Policy Watch discusses a new proposal in the Health and Human Services (HHS) Benefit and Payment Parameters for 2025 that aims to expand access to adult dental care in Affordable Care Act (ACA) Marketplace plans.

Background

While dental coverage for children under the age of 18 is an essential health benefit (EHB) under the ACA statute, adult dental care is currently prohibited by agency regulation from being considered an EHB in individual and small group plans. As a result, it is excluded from the ACA’s major cost-sharing protections that apply to EHBs such as the ban on annual and lifetime dollar limits and maximum annual limits on out-of-pocket cost sharing for consumers and is not covered by premium subsidies. There are still coverage options for adults seeking dental care through the Marketplace, offered through stand-alone dental plans (SADPs) or embedded plans (medical plans that include dental coverage). Dental care is usually subject to a deductible, though the National Association of Dental Plans reports that many dental plans waive the deductible for preventive dental care such as cleanings or cover preventive care 100%. Dental coverage that is included in an embedded plan is generally subject to the medical deductible for the plan, which, on average, was $3,057 in 2024. This translates to greater consumer cost sharing before coverage of dental services begins. In contrast, the average deductible for standalone dental plans offered on the Marketplace in 2023 was $52 according to KFF analysis of the Health Insurance Exchange Plan Attributes Public Use Files, which includes all qualified and non-qualified stand-alone dental plans sold on- and off- the exchange.

The KFF Consumer Survey of Consumer Experiences with Health Insurance finds that consumers who reported having insurance coverage at the time of the survey tend to avoid seeking dental care if the out-of-pocket costs are high. Across coverage types, at least one in four adults with health insurance report cost barriers to accessing dental care in the past year, including about four in ten of those with Medicaid (39%) and Marketplace coverage (37%) and a quarter of those with ESI (25%) and Medicare (26%) (Figure 1).

Delaying needed dental care could lead to more serious health problems down the road. Poor dental health is associated with chronic diseases such as diabetes, heart disease, and oral cancer, and could also lead to additional burdens on the healthcare system as patients seek care elsewhere.

The HHS Benefit and Payment Parameters Notice for 2025 proposes to remove the prohibition on the classification of routine adult dental health coverage as an EHB. Under this proposed rule, states would have the option of classifying adult dental care as an EHB. If a state chose to classify adult dental health as an EHB, the state (or the federal government as a fallback) would be required to enforce the same ACA protections for adult dental coverage that apply to other EHBs. They would also have the option of applying additional protections for adult dental coverage offered as an EHB that goes beyond the federal requirements for EHBs.

What Are the Key Issues to Watch?

Embedded deductibles might not provide consumers with financial protection for dental care. One issue raised in comment letters for the 2025 Payment Notice is that consumers who receive dental care through embedded dental coverage may have to meet the medical deductible before coverage of dental services can begin. If a state chooses to offer adult dental care as an EHB, medical plans would be required to cover it, and the medical deductible could apply. Deductibles under medical plans can be thousands of dollars, which may deter consumers from seeking dental care, especially people with lower incomes.

Classifying adult dental care as an EHB could come at an increased cost to the federal government and health issuers. CMS stated in the proposed rule that it does not anticipate any immediate costs as a result of giving states the option to include adult dental care as an EHB. However, it is possible that application of advanced premium tax credits towards dental care could raise costs for the federal government. Additionally, cost sharing provisions that apply to EHBs, such as the ban on annual and lifetime coverage limits and the maximum annual out of pocket limit, could increase costs for health plan issuers since they could no longer apply these restrictions on dental care.

The new provision could affect employer-sponsored plans. Small employer plans, like those in the individual market, are required to cover EHBs. While large employer plans do not have to meet EHB rules, federal regulations require that these plans choose a state benchmark in order to comply with the ACA’s prohibition on annual and lifetime dollar limits. CMS pointed out in the proposed Payment Notice that if a self-insured or fully-insured large employer plan selects a state benchmark plan that includes adult dental care as an EHB, they would be required to abide by the cost-sharing requirements that apply to other EHBs. Employer plans that offered dental plans separately as “excepted benefits” (which are not subject to ACA requirements for comprehensive medical insurance), however, would presumably not be required to abide by these requirements.

Consumers could be subject to cost-sharing for preventive dental services. The ACA requires most private health plans to cover, without cost sharing, preventive health services rated as an A or B in the United States Preventive Service Task Force recommendations; however, no adult dental services have received this A or B rating. Consumers could be subject to cost sharing for routine preventive dental services or be required to meet the deductible before coverage of preventive services began, although as stated above, many private health plans already cover preventive health services such as cleanings before the deductible.

Looking Forward

The ACA’s EHB requirements seek to ensure consumers in the individual and small group markets have comprehensive coverage that meets vital health needs. The law requires the Secretary of HHS to define EHB that covers at least 10 general categories of benefits and has a scope equal to those “under a typical employer plan.” According to the 2023 KFF Employer Health Benefits Survey, 90% of small firms and 94% of large firms offer dental insurance programs to their employees. If the proposed 2025 Payment Rule is finalized as proposed, this will allow states to choose to include adult dental care as a required benefit in state-regulated health plans. This could enhance efforts to increase access to dental care, especially for lower income adults who are particularly susceptible to having unmet dental health needs. In addition, KFF research shows that dental costs are a contributor to medical debt. CMS and states may evaluate the most appropriate ways to structure an adult dental benefit that provides financial protections to avoid debt for common basic care, balanced by potential increases in federal costs.

About 1 in 8 voters (12%) now say that abortion is the most important issue for their vote in the 2024 elections, highlighting how the issue could motivate groups of voters who largely say abortion should be legal in all or most cases, a new KFF Health Tracking Poll finds.

The issue resonates with certain key groups of women voters. More than 1 in 4 Black women voters (28%), and about a fifth of Democratic women (22%), women who live in states where abortion is banned (19%), women voters who plan to vote for President Biden (19%), and women of reproductive age (18-49) (17%) identify as abortion voters.

Overall, the majority of abortion voters say abortion should be legal in all or most cases. This is a significant shift from elections prior to the Supreme Court’s decision to overturn Roe v. Wade, when abortion voters were largely those who identified as pro-life.

About half (48%) of this election’s abortion voters say that they would vote for President Biden if the election were held today, nearly double the share (26%) who say that they would vote for former President Trump. This group says they voted for Biden over Trump by a similar margin in 2020, though about 1 in 5 say they did not vote in that election.

At the same time, 43% of Republicans overall say abortion should be legal in all or most cases, but few Republicans who want abortion to be legal seem ready to buck their party over the abortion issue. In tight races, however, even small shifts could become important. Republicans who say abortion should be illegal are more likely to be abortion voters (14%, or 8% of all Republican voters) than those who say abortion should be legal (4%, or 2% of all Republican voters).

Partisans largely trust their own party and their own party’s presumptive nominee more on the issue of abortion. Larger shares of independent voters trust the Democratic Party (38%) and President Biden (35%) than the Republican Party (15%) and former President Trump (19%), though a significant share of independent voters say they don’t trust either party (39%) or candidate (31%) on this issue. 

About half of voters overall say this year’s presidential election (51%), Congressional election (53%), and which party controls their state legislature (55%) will have a “major impact” on access to abortion. The shares who say it will have a major impact rises to at least two-thirds among abortion voters and Democratic voters.

Majorities, Including Most Women of Reproductive Age, Favor Policies to Protect Abortion Access and Oppose Policies that Could Restrict It

The poll also gauges the public’s support for specific abortion policies, including a national 16-week abortion ban that media reports suggest Trump is considering for his platform.

Most of the public (58%), including most women under age 50 (61%), oppose a national 16-week abortion ban, though most Republicans (63%) would favor it.

On other policy changes, the poll finds the public overall – and most Democrats – largely supportive of policies protecting access to abortion. Examples include:

• Adults (86%) overwhelmingly say they support protecting access to abortion for patients experiencing pregnancy-related emergencies, such as miscarriages. This includes large majorities of Democrats, independents, and Republicans.
• Two thirds (66%) support guaranteeing a federal right to an abortion, including three quarters (76%) of women under age 50. Large majorities of Democrats (86%) and independents (67%), and a sizeable minority of Republicans (43%), support such a guarantee.
• Most of the public opposes several policies advocated by abortion opponents, such as making it a crime for health care providers to mail abortion pills to patients in states where abortion is prohibited (62% oppose) and policies that prohibit clinics that receive federal funds from providing abortions or referring patients to abortion providers (61% oppose). Narrow majorities of Republicans support each of those policies.

The public’s views on specific policies likely reflect their broader views of abortion. When asked how they think about abortion, most of the public says it is an issue of individual rights and freedoms (81%), a health care issue (68%), and a moral issue (62%). This includes at least half of Democrats, independents, and Republicans. Fewer see it as a religious issue (41%), though most Republicans (55%) do.

Other poll findings include:

• Former President Trump has taken credit for the Supreme Court’s decision to overturn Roe v. Wade, as the three justices he appointed to the court joined that decision. About two thirds of voters (65%) say he had at least some responsibility for the decision, including half of Republican voters.
• On March 26, the Supreme Court will hear arguments in a case that could affect access to mifepristone, a drug used for medication abortion that can currently be prescribed via telehealth and mailed to patients. About two thirds (64%) of the public has not heard anything about the case.
• In the wake of the Supreme Court’s decision to end the constitutional right to abortion, just under half (45%) of adults say they consider the right to use contraception as “secure,” while one in five (21%) say it is “a threatened right likely to be overturned,” and a third (34%) say they are not sure whether the right is threatened or secure. Among partisans, Democrats are most likely to see the right to contraception as threatened (38%).

Designed and analyzed by public opinion researchers at KFF, the survey was conducted from February 20-28, 2024, online and by telephone among a nationally representative sample of 1,316 U.S. adults, including 1,072 registered voters. 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 4 percentage points for the sample of registered voters. For results based on other subgroups, the margin of sampling error may be higher.

Patient-provider email messaging accelerated early in the COVID-19 pandemic as more patients sought medical care remotely, and the addition of billing codes for digital health services and subsequent changes in insurers’ payment policies have enabled providers to bill insurers and patients for messaging. This analysis examines the typical cost of patient-provider email messaging in 2020 and 2021 using private health insurance claims data.

The typical cost for an email messaging claim was $39 in 2021, including both the portion paid by insurance and that paid by patients. Although the health plan covered the full cost for most of these claims (82%), those patients with at least some out-of-pocket costs typically paid $25.

The analysis is available through the KFF-Peterson Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

The first FDA-approved over-the-counter daily oral contraceptive pill in the United States— Perrigo’s Opill— is now available for pre-order at major online retailers and will soon be available in stores.

Although the new over-the-counter pill could broaden access to contraceptive options in the United States, KFF research suggests consumers are likely to face some hurdles if they seek to have their plan cover the costs. For example, while federal policy requires most private health insurance plans and Medicaid expansion programs to cover—without patient copays—the full range of FDA-approved contraceptive methods with a prescription, there is no federal requirement that plans cover nonprescription contraception.

As Opill officially launches and federal regulators consider public input on how best to ensure coverage and access to over-the-counter preventive services like it, these three charts provide insights into the coverage and affordability issues raised by the over-the-counter availability of these pills.

1) Many women who say they are likely to use an over-the-counter oral contraceptive pill say they would not be willing to pay Opill’s suggested retail price.

The suggested retail price of Opill is $19.99 for one month’s supply or $49.99 for three months’ supply. Four in ten (39%) of those who say they are likely to use over-the-counter pills say they would be willing and able to pay $1-$10 per month and 11% would not be willing to pay anything ($0) for the pills. A third (34%) would pay $11-$20.

2) More than one third of oral contraceptive users have missed taking their birth control because they were unable to get their next supply on time.

Traditionally, patients need to get a prescription for oral contraceptives from a clinician and then pick up their supply at a pharmacy. Dispensing qualities vary by insurer, but the vast majority of oral contraceptive pills users receive fewer than 6 packs of pills at a time. The added convenience and time saved by obtaining oral contraception directly in stores or having them delivered from online retailers could reduce the share of women who miss taking their contraception on time because of difficulties in keeping a continuous supply on hand.

3) Seven states require state-regulated private health insurance plans to cover at least some methods of over-the-counter contraception without a prescription free of cost-sharing, and seven states use state funds to offer the same coverage for Medicaid enrollees.

Several states have taken action to address affordability barriers to over-the-counter contraception by requiring plans to cover certain products such as emergency contraception and condoms without a prescription. However, the reach of these measures is limited because the majority of those with private health insurance are enrolled in plans that are only subject to federal laws, not to state laws. In most of these states, the language of these private health insurance policies is broad enough to include an over-the-counter daily oral contraceptive such as Opill without a change in policy.

KFF has many resources about Opill’s potential impact and the coverage landscape in which the pill will be available. Take a deeper dive into the following:

• Insurance Coverage of OTC Oral Contraceptives: Lessons from the Field
• Will Insurance Cover Over-the-Counter Contraceptive Pills? A Discussion of Coverage Options and Challenges
• Over-the-Counter Oral Contraceptive Pills
• Oral Contraceptive Pills: Access and Availability
• Interest in Using Over-the-Counter Oral Contraceptive Pills: Findings from the 2022 KFF Women’s Health Survey

Note: For the latest information on states with approved HRSN waivers, view our  Section 1115 tracker “Key Themes Maps.”

In December 2022, the Centers for Medicare and Medicaid Services (CMS) announced a Section 1115 demonstration waiver opportunity to expand the tools available to states to address enrollee health-related social needs (or “HRSN”). In November 2023, CMS released a detailed Medicaid and CHIP HRSN Framework accompanied by an Informational Bulletin (CIB). CMS defines health-related social needs as an individual’s unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to poor health and are a result of underlying social determinants of health (SDOH). CMS outlines federal guardrails and requirements attached to the new demonstration opportunity (e.g., expenditure limits, service delivery requirements, and monitoring and evaluation requirements). CMS indicates broadening the availability of HRSN services is “expected to promote coverage and access to care, improve health outcomes, reduce health disparities, and create long-term, more cost-effective alternatives or supplements to traditional medical services.” While health programs like Medicaid can play a supporting role, CMS stresses the new HRSN initiatives are not designed to replace other federal, state, and local social service programs but rather to complement and coordinate with these efforts. And, the amount of funding allocated to HRSN programs is modest as a share Medicaid spending in states with approved waivers.

This issue brief identifies states with approved and pending Medicaid 1115 waivers with SDOH-related provisions and summarizes approvals under the new Biden administration HRSN 1115 framework, highlighting approved services, target populations, and key requirements related to financing HRSN services.

As of February 2024, the Biden administration has approved eight 1115 demonstrations under the new HRSN waiver framework (Figure 1). These waivers authorize evidence-based housing and nutrition services for specific high-need populations. Several approvals build on prior 1115 waiver initiatives (including California’s “CalAIM” transformation). Approvals include coverage of rent/temporary housing and utilities for up to 6 months and meal support up to three meals per day (for up to 6 months), departing from longstanding prohibitions on payment of “room and board” in Medicaid.¹  Eleven other states have approved 1115 waivers with SDOH-related provisions that pre-date the new Biden administration HRSN framework. These waivers are generally narrower in scope (services and target populations) or pilot programs targeting specific regions. For example, in October 2018, CMS approved North Carolina’s Healthy Opportunities Pilots, that operate in three geographic regions. Six additional states have SDOH-related 1115 waivers pending review at CMS.

The remainder of this brief highlights key provisions approved under the new HRSN 1115 framework in eight states (Arizona, Arkansas, California, Massachusetts, New Jersey, New York, Oregon, and Washington).

What HRSN services are states covering through recently approved 1115 waivers?

Authorized HRSN services include housing supports, nutrition supports, and case management but specific services offered vary by state demonstration (Appendix Table 1). States can add HRSN services to the benefit package and may require managed care plans to offer the services to enrollees who meet state criteria.

• Housing Supports. All states have approval to provide housing supports without “room and board” such as housing transition and navigation services, tenancy sustaining services (e.g., tenant rights education, eviction prevention), one-time transition and moving costs, home remediations, and home accessibility modifications. Some states have approval to provide housing supports with “room and board” including recuperative care (also called medical respite) and short-term housing and utility assistance (up to 6 months). As of February 2024, four states (Arizona, New York, Oregon, and Washington) have CMS approval to cover rent/temporary housing and utility costs for up to 6 months. Three states (California, New York, and Washington) have approval to cover recuperative care (up to 90 days) and short-term post-hospitalization housing (up to 6 months).
• Nutrition Supports. Approved nutrition services include nutrition counseling, home delivered meals or pantry stocking, nutrition prescriptions, and grocery provisions (meal/nutrition supports approved up to 3 meals/day, for up to 6 months). Nutrition services are frequently tailored to health risk or designed to support individuals with specific nutrition-sensitive health conditions (e.g., diabetes). Two states (Massachusetts and New York) have approval to provide additional meal/nutrition support for a household with a high-risk child or pregnant individual.

All states will also provide HRSN case management, outreach, and education services. A few states also have approval to cover transportation to HRSN services (Massachusetts, New York, and Washington). All states have CMS approval for HRSN infrastructure expenditures to support the implementation and delivery of HRSN services. Infrastructure investments may include technology; development of business or operational practices; workforce development; and outreach, education and stakeholder convening.

What populations will have access to HRSN services?

The target populations for HRSN services vary but in all instances are narrowly defined groups that must meet specified health and social risk criteria (Appendix Table 2). Subject to CMS approval, states have flexibility to define the target populations eligible to receive HRSN services, using clinical and social risk criteria. HRSN services must be medically appropriate and voluntary for enrollees. Target populations approved include individuals who are or are at risk of becoming homeless, individuals with serious mental illness (SMI) and/or substance use disorder (SUD), high-risk pregnant individuals, high-risk children/youth, and individuals experiencing high-risk care transitions (e.g., from institutional care, correctional setting, or child welfare system). CMS guidance specifies housing services that include “room and board” may only be offered to populations experiencing certain housing or care transitions (e.g., individuals experiencing homelessness, or individuals transitioning from institutions to the community).² 

What are key CMS requirements related to financing HRSN services under 1115?

Recent CMS changes to budget neutrality policy may create broader opportunities for states to pursue HRSN initiatives, but guidance also sets financing limits and guardrails. While not set in statute or regulation, a longstanding component of Section 1115 waiver policy is that waivers must be budget neutral for the federal government (i.e., federal costs under a waiver must not exceed what they would have been for that state without the waiver). In its approvals, CMS has indicated that HRSN spending will not require offsetting savings. In addition, CMS has specified that states may access federal matching funds for spending on “Designated State Health Programs (DSHP)” (which may free up state funds to finance HRSN initiatives), a policy that was phased out under the Trump administration. In conjunction with policies to broaden financing opportunities for HRSN, CMS has also included fiscal guardrails and requirements aimed at ensuring states prioritize coverage and access to basic medical services and ensuring HRSN spending complements, rather than supplants, existing local, state, and federal social supports. Key requirements include:

• CMS is limiting how much Medicaid funding a state can use for HRSN initiatives. CMS guidance specifies spending for HRSN services and infrastructure cannot exceed 3% of total annual Medicaid spending. HRSN infrastructure cannot exceed 15% of the state’s total HRSN expenditure authority. Waivers include spending caps (based on a state’s projected expenditures) for HRSN services and infrastructure (Appendix Table 3). States will not have access to federal matching funds for any spending above the cap. In its approvals, CMS indicates the HRSN spending caps “will ensure the state maintains its investment in the state plan benefits to which enrollees are entitled while testing the benefit of the HRSN services.”
• CMS is requiring states to meet provider payment rate requirements for core Medicaid services. To maintain and/or improve access to quality care for enrollees, as a condition of approval, states are required to maintain base Medicaid payment rates (fee-for-service and managed care) of at least 80% of Medicare rates for primary care, behavioral health, and obstetrics services and must increase rates that are below this level.
• Medicaid-covered HRSN services should complement but not supplant the work or funding of other federal or state non-Medicaid agencies. In addition, CMS guidance outlines state spending on related social services (before the waiver) must be maintained or increased.

What to watch as HRSN waivers move to implementation?

Looking ahead, the results of required monitoring and evaluation of HRSN initiatives could help inform future policy decisions about whether and how to use Medicaid to address enrollees’ health-related social needs. States are required to submit implementation plans and protocols to CMS for review and approval that provide operational details for new initiatives. States are also required to submit quarterly and annual monitoring reports to CMS that provide information on HRSN service implementation, HRSN service utilization, and quality of services. Finally, states must submit an evaluation strategy to CMS for review and approval. Independent evaluations must test whether HRSN services effectively address unmet HRSN, reduce potentially avoidable, high-cost services, and/or improve physical and mental health outcomes. States will also be required to report on health equity metrics. Implementation timing will vary across states. California began implementation of its “community supports” in 2022 (authorized under 1115 and managed care “in lieu of” authorities). Available implementation plans suggest two states (Arizona and Oregon) expect to roll out HRSN services in 2024, while Massachusetts plans to begin offering HRSN services in 2025. Implementation information from remaining states is forthcoming. Waiver priorities often shift from one presidential administration to another, so states’ ability to continue to pursue these initiatives may hinge on the outcome of the 2024 election.

Appendix Tables

1. Federal financial participation is not available to state Medicaid programs for room and board except in certain medical institutions, as codified in multiple regulatory provisions. See, for example, 42 CFR § 441.310(a)(2) and 42 CFR §441.360(b). CMS defines board as three meals a day or any other full nutritional regimen, and room as hotel or shelter type expenses including all property related costs such as rental or purchase of real estate and furnishings, maintenance, utilities, and related administrative services. See section 4442.3 of the State Medicaid Manual at www.cms.gov/regulations-andguidance/guidance/manuals/paper-based-manuals-items/cms021927. ↩︎
2. Allowable transitions include out of institutional care (NFs, IMDs, ICFs, acute care hospital); out of congregate residential settings such as large group homes; individuals who are homeless, at risk of homelessness, or transitioning out of an emergency shelter as defined by 24 CFR 91.5; out of carceral settings; and individuals transitioning out of the child welfare setting including foster care. https://www.medicaid.gov/sites/default/files/2023-11/hrsn-coverage-table.pdf ↩︎

The Affordable Care Act does not require businesses to provide health benefits to their workers, but applicable large employers may face penalties if they don’t make affordable coverage available. The employer shared responsibility provision of the Affordable Care Act penalizes employers who either do not offer coverage or do not offer coverage that meets minimum value and affordability standards. These penalties apply to firms with 50 or more full-time equivalent employees. This flowchart illustrates how those employer responsibilities work.

Figure 5 was updated on March 11, 2024, to correct an error in the bar showing data for immigrants who speak English exclusively or very well.

Immigration has been a hot-button issue in U.S. political debate for decades, with immigration policy at the federal level often shifting dramatically between presidential administrations. For example, under longstanding U.S. policy, federal officials can deny an individual entry to the U.S. or adjustment to lawful permanent status (a green card) if they determine the individual is a “public charge” based on their likelihood of becoming primarily dependent on the government for subsistence. In 2019, the Trump Administration made changes to this policy to newly consider the use of noncash assistance programs, including Medicaid, in public charge determinations. In 2022, the Biden Administration reversed these changes, but many immigrant families remain confused and uncertain about the policy.

Political debates and campaign statements about immigration can further contribute to confusion and fear among immigrant families. Immigration has emerged as a key issue in the 2024 presidential election campaign, with Donald Trump indicating plans to vastly restrict immigration and conduct mass deportations of undocumented immigrants if elected, and with President Biden facing criticism over the crisis at the U.S.-Mexico border. Amid this environment, immigrants’ understanding of immigration laws has implications for their feelings of security and willingness to access assistance programs that may support their and their children’s well-being. Below are five key facts about immigrants understanding of U.S. immigration laws drawing on the 2023 KFF/LA Times Survey of Immigrants. For methodological details of the survey, more KFF analysis, and reporting from the LA Times, please visit the overview report, Understanding the U.S. Immigrant Experience.

About half of immigrants say they do not have enough information to understand how U.S. immigration policies impact them and their families.

This share rises to seven in ten (69%) immigrants who are likely undocumented and six in ten of those with limited English proficiency (58%) or lower incomes (57%) (Figure 1). Confusion and lack of information may contribute to fears among immigrant families and lead some immigrants to avoid accessing assistance programs that could ease financial challenges and facilitate access to health care for themselves and their children, who are often U.S.-born. Confusion and fears may escalate amid growing immigration policy debates.

About six in ten (58%) immigrants are not sure whether use of government programs that help pay for health care, housing, or food will decrease an immigrant’s chance of getting a green card.

Another 16% incorrectly believe this to be the case. Among immigrants who are likely undocumented, nine in ten are either unsure (68%) or incorrectly believe use of these types of public programs will decrease their chances for green card approval (22%). These findings highlight the importance of continued outreach and education efforts to help immigrants understand public charge policies.

One in twelve immigrants say they have avoided noncash government assistance programs because they didn’t want to draw attention to their or a family member’s immigration status, rising to one in five among those who believe the use of noncash assistance will decrease one’s chances of getting a green card.

These shares are even higher among immigrants in households with incomes below $40,000 and those who are noncitizens, suggesting that immigration-related fears and confusion about public charge rules have consequences, particularly for immigrants who may have the greatest need for these assistance programs.

One in four immigrants with limited English proficiency (LEP) say that difficulty speaking or understanding English has made it hard for them to apply for government financial help with food, housing, or health coverage.

This includes three in ten (31%) immigrants with LEP who have household incomes under $40,000. Beyond fears and confusion, lack of linguistically accessible information and assistance may serve as an additional barrier for immigrants to access assistance programs. Among immigrants with LEP, about six in ten (62%) speak Spanish, 7% speak a dialect of Chinese, 4% speak Vietnamese, and smaller shares speak a variety of other languages, highlighting the importance of accessible information in multiple languages.

Immigrants say they use a variety of sources for information on U.S. immigration policy, including search engines, U.S. government websites, and attorneys or other professionals.

Asked where they would go if they had a question about U.S. immigration policy, about one third of immigrants say they would go to a search engine such as Google first; another third say they would go directly to a U.S. government website. One in six (16%), rising to nearly four in ten likely undocumented immigrants (38%), say they would consult an attorney or other professional. Immigrants with LEP are split between using a search engine like Google (30%), a U.S. government website (26%) or an attorney or other professional (24%). The findings highlight the importance of having accurate and trusted online information sources for immigrants that are available in multiple languages. They also illustrate the potential vulnerability of immigrants to misinformation online and immigration scams.

According to an analysis of responses to KFF’s Employer Health Benefits Survey in 2023, relatively few (8%) large firms (with 200 or more workers) offering health benefits report reducing or expanding coverage for abortion since the U.S. Supreme Court overturned Roe v. Wade with the Dobbs v. Jackson ruling.

Since Dobbs, 3% of these large firms reduced or eliminated coverage for abortion where it is legal. Meanwhile, 12% of large firms whose largest plan covers abortion under most or all circumstances, added or expanded abortion coverage following the ruling.

One-third (32%) of large firms that offer health benefits cover abortion in most or all circumstances in their largest health plan, while almost as many (28%) cover it under limited circumstances or not at all.

The survey also revealed a general lack of awareness of abortion coverage among respondents at large firms that offer health benefits. Forty percent said they didn’t know if their largest plan covers abortion. A possible reason for this could be because of limited information about abortion coverage in plan documents unless abortion is explicitly excluded. Additionally, survey respondents are generally human resources or benefits managers, though they are typically not legal experts.

With abortion banned or severely limited in some states, people residing in those states must now also shoulder costs related to traveling to states where abortion is legal. Seven percent of large employers offering health benefits say they provide, or plan to provide, financial assistance for travel expenses for enrollees who must go out of state to obtain a legal abortion. Very large employers (with 5,000 or more workers) are most likely to provide, or plan to provide, such travel reimbursements (19%).

Reflecting the politics around abortion policies, larger shares of large firms offering health benefits that are headquartered in the Northeast (56%) and West (44%)—where few states ban abortion—provide coverage of abortion in their largest health plan in most or all circumstances. This finding contrasts with large firms in the Midwest (20%) and South (18%). Relatedly, a small fraction of large firms that offer health benefits that are headquartered in the Northeast (2%) and West (4%) didn’t cover abortion under any circumstances, compared to slightly larger shares in the Midwest (14%) and South (15%).

Employer-sponsored health insurance is the largest source of coverage in the United States, covering 153 million people younger than age 65 in 2023. For 25 years, the annual KFF Employer Health Benefits Survey has asked private firms and non–federal government employers with three or more employees about the characteristics of their health plans. The specific benefits and services covered by those plans are shaped by many factors including costs, employer policies and beliefs, and state and federal regulations. Since the June 2022 U.S. Supreme Court’s Dobbs v. Jackson ruling overturning Roe v. Wade, there has been increased public and media attention about people with no or limited access to abortion, but little is known about abortion coverage in employer-sponsored plans.

This brief presents findings from the 2023 KFF Employer Health Benefits Survey on coverage of abortion services in large employer-sponsored health plans, changes employers made to abortion coverage since the 2022 Supreme Court ruling, and employers’ provision of financial assistance for travel out of state to obtain an abortion. This is the first survey of its kind to analyze coverage for abortion in employer-sponsored health plans. The survey was fielded from January through July 2023 and asked employers with 200 or more employees about their coverage policies for abortion.

Background

Ten states have laws that prohibit all state-regulated private plans from including abortion coverage. Most, but not all, have exceptions for pregnancies resulting from rape or incest or in cases in which it poses a threat to the life of the pregnant person. Conversely, ten states have enacted policies that require coverage of abortion services in all state-regulated private plans. In addition to individual and fully-insured group plans, states also regulate plans offered to state and local government employees.

However, neither the state-level abortion coverage inclusion nor prohibition requirements apply to all plans offered to workers in these states. Self-funding health care services for workers instead of purchasing a health insurance plan is a common practice among larger employers and those type of arrangements are regulated by the federal Employee Retirement Income Security Act of 1974 (ERISA). This law generally exempts self-funded plans offered by private employers from state insurance regulations. In total, 67% of covered workers at large firms are enrolled in a plan that is preempted from state insurance laws because their plan sponsors are non-public employers and the plan is self-funded.

Absent state insurance laws requiring or prohibiting coverage of abortion in state regulated plans, private employers offering self-funded plans may choose whether to offer coverage for abortion, or to only cover it under limited circumstances such as in cases of rape or incest or health endangerment of the pregnant person. The federal Pregnancy Discrimination Act states that employer health benefits plans that cover pregnancy services shall cover abortion in cases of life endangerment of the pregnant person or where medical complications have arisen from an abortion.

Findings

Coverage for Abortion Services

Ten percent of large firms (200 or more workers) that offer health benefits do not cover legally provided abortions under any circumstance in their largest plan; 18% cover abortion only under limited circumstances, such as rape, incest, or health/life endangerment; and 32% cover abortion in most or all circumstances (Table 1). Notably, 40% of those responding on behalf of large firms that offer health benefits do not know if their largest plan covers abortions, part of which could be attributed to lack of information about coverage for abortion in plan documents unless abortion is explicitly excluded. Survey respondents are generally human resources or benefits managers, though they are typically not legal experts (we ask to speak with the person at the firm who is most knowledgeable about the firm’s health benefits).

Forty-three percent of the largest firms with 5,000 or more workers that offer health benefits report that they cover abortion in most or all circumstances, compared to 34% of firms with 1,000-4,999 workers and 31% of firms with 200-999 workers (Table 1). A higher share of firms with 5,000 or more workers (30%) that offer health benefits cover abortion in limited circumstances only compared to firms with 1,000-4,999 workers (19%) and firms with 200-999 workers (17%). This juxtaposition can be attributed in part to the substantially higher share of smaller large firms reporting that they do not know if their largest plan covers abortion compared to the largest firms. Knowledge of the plan’s abortion benefits increases with firm size. Forty-two percent of large firms offering health benefits with 200-999 workers responded “Don’t know” to this question, decreasing to 18% of firms with 5,000 or more workers.

In addition, a large share of public firms (51%) reported that they do not know if their plan covers abortion, a significantly higher share than private for-profit (37%) and private not-for-profit firms (39%). Large public firms (23%), such as state and local governments, that offer health benefits are less likely to cover legally provided abortions in most or all circumstances in their largest plan than private for-profit (34%) or private not-for-profit firms (32%) (Table 1).

More large firms whose largest plan is self-funded (12%) report that they do not cover legally provided abortions under any circumstance than firms whose largest plan is fully-insured (6%), or that they cover abortion only in limited circumstances (21% vs. 14%) in their largest plan (Table 1). However, 49% of employers whose largest plan is fully-insured and 33% whose largest plan is self-funded report not knowing whether abortion is covered in their largest plan. On average, larger firms are more likely to be self-funded and larger firms are more likely to cover abortion. Therefore, differences by firm funding may be related to characteristics other than how the firm structures the plan.

Looking at the region in which the firm is headquartered, more than half (56%) of large firms offering health benefits and headquartered in the Northeast cover abortion in most or all circumstances in their largest plan, compared to those in the West (44%), Midwest (20%), and the South (18%). Large firms offering health benefits in the South (15%) and Midwest (14%) are more likely than firms headquartered in other regions of the country not to cover abortion under any circumstance in their largest plan (Table 1). A larger share of firms headquartered in the South (47%) than those headquartered in other regions of the country report that they do not know if their plan covers abortion, perhaps reflecting the complexity and changing landscape of abortion laws in many of these states. Although where a firm is headquartered is not necessarily where its largest plan is offered, these findings do largely mirror trends related to abortion rights and abortion coverage laws in states in these regions. See the survey methodology section for the classification of states into regions.

Changes in Coverage for Abortion Since the Dobbs v. Jackson ruling

The 2023 KFF Employer Health Benefits Survey also asked firms whether they had made any changes to their largest plan’s coverage of abortion following the U.S. Supreme Court’s ruling in Dobbs v. Jackson.

The ruling made national headlines and resulted in considerable changes in state-level abortion laws, which may have prompted some employers to review their plan’s abortion coverage, but overall, relatively few (8%) large firms offering health benefits report reducing or expanding coverage for abortion since the ruling. The vast majority of large firms whose largest plan does not cover abortion or only covers it in limited circumstances already had this coverage restriction prior to the Dobbs v. Jackson ruling (Figure 1). Overall, just 3% of these firms reduced or eliminated coverage for abortion where it could legally be provided since the ruling. Conversely, 12% of large firms whose largest plan covers abortion under most or all circumstances added or expanded this coverage following the ruling.

Financial Assistance for Out-of-State Travel for Abortion

Another aspect of employer coverage of abortion that has garnered increased public attention since the Dobbs v. Jackson ruling is employers providing financial assistance for travel expenses, such as airfare and lodging, for enrollees who have to travel out of state to obtain an abortion. In response to a growing number of state bans and restrictions that have made it more difficult to obtain an abortion in some states, several large companies announced that they would begin offering this benefit. Currently, fourteen states have banned abortion except in limited circumstances and many more have implemented restrictions such as early gestational stage limits, and additional requirements such as waiting periods and ultrasounds for obtaining an abortion, leading some pregnant people to have to travel to another state to obtain abortion care.

Overall, few firms offer this travel benefit. Among large firms that offer health benefits, only 7% said they provide or plan to provide financial assistance for travel expenses for enrollees who travel out of state to obtain an abortion if they do not have access near their home (Table 2). Twenty-seven percent of large firms offering health benefits do not know if the firm provides or plans to provide this assistance.

This benefit is significantly more common among firms with 5,000 or more workers (19%) than firms with 1,000-4,999 workers (10%) or firms with 200-999 workers (6%). Public firms (1%) are substantially less likely than private for-profit firms (8%) and private not-for-profit firms (10%) to cover out-of-state travel for abortion. A larger share of firms offering health benefits headquartered in the Northeast (13%) offer this benefit compared to those headquartered in other regions of the country. There are no statistically significant differences in firms offering this benefit by plan funding arrangement.

Eighteen percent of large firms that cover abortion in most or all circumstances in their largest plan also provide, or plan to provide, enrollees financial assistance for travel out of state to obtain an abortion, compared to 4% of those that cover abortion only in limited circumstances and 1% of those that do not cover abortion under any circumstances (data not shown).

Discussion

The majority of people in the U.S. have employer sponsored health insurance, so the coverage decisions that employers make play a role in access to care, including for abortion services, for covered workers and their enrolled dependents.

One-third of large firms that offer health benefits cover abortion in most or all circumstances in their largest health plan, while almost as many cover it under limited circumstances or not at all. However, four in ten respondents do not know whether their largest plan covers abortion. In some cases, this could be because plan documents such as summaries of benefits do not always contain information about coverage for abortion. The changing legal landscape in many states and the complexity of the issue could also explain some of respondents indicating they did not know. Survey respondents are generally human resources or benefits managers, though they are typically not legal experts.

If coverage for abortion is not mentioned in enrollee-facing plan documents, plan enrollees also may not be aware of their plan’s coverage policy for abortion without having to ask the plan (or third-party administrator) or their employer. This issue has gained more importance to policyholders, as 9 states have instituted laws that require state-regulated plans to include abortion as a covered benefit and to cover abortion care without cost-sharing, including copayments, coinsurance, or deductibles.

A less discussed law that could also affect coverage of abortion in certain cases is the Pregnancy Discrimination Act (PDA), which applies to employers with 15 or more workers. The PDA requires employer-sponsored health insurance to cover abortion in cases where the life of the pregnant person is endangered if the fetus were carried to term or where medical complications have arisen from an abortion. Some survey respondents may be unfamiliar with the Pregnancy Discrimination Act’s requirements when, in fact, the plan or third-party administrator must cover abortion in these very limited situations.

While the ruling in Dobbs v. Jackson and subsequent state activities pertaining to abortion have increased public interest in how abortion services are covered by employer-provided plans, so far, relatively few employers have changed their plan’s existing coverage for abortion since this ruling or decided to offer financial assistance for travel. This could be in part because employers are still considering their options under the current legal landscape (e.g., employers that choose to cover abortion services may still be subject to state civil and criminal penalties in states that prohibit “aiding or abetting” an abortion) or because benefits for the 2023 plan year may have already been finalized by the time Dobbs was decided. The extent to which employers continue to change their plan’s coverage for abortion or begin covering certain travel expenses, and the extent to which enrollees utilize these benefits, is not yet known.