A new KFF analysis of provisional 2022 data from the Centers for Disease Control shows that the recent increases in firearm death rates among children and adolescents ages 17 and under were driven largely by gun assaults, which accounted for 66% of firearm deaths among young people in 2022, up from 54% in 2019.

Data also show that in 2022, seven children ages 17 and below per day died by firearm, similar to 2021. This caps a decade in which firearm death rates gradually rose until 2017, then slowed through 2019 before climbing sharply by 46% from 2019 to 2022. 

From 2012 to 2022, nearly 19,700 children ages 17 and younger died by firearm. The analysis shows that both the national rise in overall firearm-related deaths and those specifically involving gun assaults have disproportionately affected Black and Hispanic children and adolescents. In 2022, the rate of firearm deaths among Black youth was 12.2 deaths per 100,000 people – higher than any other racial and ethnic group and six times higher than White youth.

Additionally, since the onset of the pandemic, the gap in gun assault death rates between Black and White children and adolescents has significantly widened. As a result of worsening trends in firearm deaths, in 2022, Black youth accounted for 48% of all youth firearm deaths although they made up only 14% of the U.S. youth population. Exposure to gun violence disproportionately impacts Black youth and gun violence exposure is linked to poor mental health and substance use outcomes.

Overall, as in 2021, more children and adolescents in the U.S. now die by firearms than from any other single cause, including motor vehicle crashes. Compared to its peer countries, the U.S. has by far the highest rate of child and teen firearm mortality. 

Other key findings include:

• Male children and adolescents are over four times more likely than their female peers to die by firearm. From 2018 to 2022, the rate of deaths due to firearms increased by 50% among male children and adolescents but remained lower and stable among females.
• Among child and adolescent firearm deaths in 2022, 27% were due to suicides and 5% were accidental. Suicides by firearm have increased over the past decade among children and adolescents, peaking in 2021 with 827 deaths before declining to 686 deaths in 2022.
• Firearm death rates among children and adolescents vary by state; however, almost all states have seen a growth in these death rates in pandemic years. Louisiana, Mississippi, and the District of Columbia were the states or areas with the highest firearm death rates among children and adolescents, while Massachusetts, New Jersey, and New York were the states with the lowest. 
• Exposure to gun violence is linked to post-traumatic stress disorder and anxiety, in addition to other mental health concerns among youth. Gun violence may also lead to challenges with school performance, including increased absenteeism and difficulty concentrating.

Following recent news about former President Trump’s potential support for a national 16-week abortion ban, KFF examines the data about how often abortions later in pregnancy occur, exploring the potential reasons why, and detailing the various laws that regulate access to abortions later in pregnancy.

The updated analysis considers 2021 CDC data, before the Dobbs decision, in a post-Dobbs policy landscape. The analysis shows that abortions at or after 21 weeks are uncommon and represent 1% of all abortions in the U.S. Ninety-six percent occurred at or before 15 weeks gestation, while 3% occurred from 16 to 20 weeks gestation.

Notably, discussions about abortions occurring later in pregnancy are often fraught with misinformation; in fact, abortions occurring “moments before birth” or even “after birth” are illegal in the U.S. and do not occur.

KFF also looks at the other issues with abortions later in pregnancy, including the expense of the procedures, which often require travel and lost wages, and the lack of availability given that they are only performed by a fraction of abortion providers. Additionally, KFF explores why people seek abortions later in pregnancy, including medical concerns such as fetal anomalies, maternal health, or life endangerment, as well as barriers to care that cause delays in obtaining an abortion.

For more information, read the full brief.

Text and figures 1 and 5 were updated on July 23, 2024 to reflect policy updates in Maryland & Michigan. 

Introduction

Abortions occurring at or after 21 weeks gestational age are rare. They are often difficult to obtain, as they are only available in a handful of states, performed by a small subset of abortion providers and are typically costly and time-intensive. Yet, these abortions receive a disproportionate share of attention in the news, policy and the law. Discussions on this topic are often fraught with misinformation; for example, intense public discussions have been sparked after several presidential candidates claimed there were abortions occurring “moments before birth” or even “after birth.” In reality, these scenarios do not occur, nor are they legal, in the United States. Discussion of this topic is distorted and inflamed by the terminology that is sometimes used to describe abortions later in pregnancy— including “late-term,” “post-viability,” “partial birth,” “dismemberment” and “born-alive” abortions. There have been some news reports of former President and current Republican presidential candidate Donald Trump’s support of a national 16-week abortion ban that would eliminate access to abortions later in pregnancy except when the life of the pregnant person is in danger or the pregnancy is a result of rape/incest. This brief explains why individuals may seek abortions later in pregnancy, how often these procedures occur, and the various laws which regulate access to abortions later in pregnancy across the country.

What is a so-called “late-term” abortion?

“Late term” abortion typically refers to abortions obtained at or after 21 weeks, however it is not an accepted medical term, nor is there a consensus around to which gestational ages it refers. Members of the medical community have criticized the term “late-term” abortion, as it implies abortions are taking place after a pregnancy has reached “term” (37 weeks) or “late term” (>41 weeks) which is false. In fact, the American College of Obstetricians and Gynecologists (ACOG) has written that “late-term abortion” has no medical meaning. As such, this brief discusses abortions occurring at ≥21 weeks gestation as abortions later in pregnancy, but it should be noted that 21 weeks is a largely arbitrary cutoff based on how the CDC collects data on abortions. Abortions at this stage in pregnancy are sometimes referred to as “later abortions” by the medical community as well.

How do states restrict or regulate abortions later in pregnancy?

On June 24, 2022, in Dobbs v. Jackson Women’s Health, the Supreme Court overturned Roe and eliminated the federal constitutional standard that had protected the right to abortion. Without any federal standards, states can now set their own policies banning or protecting abortion at any point in pregnancy. This has drastically changed the landscape of abortion in the United States, as 14 states have now banned abortion at any stage of pregnancy and 11 others have gestational limits banning abortion after a certain point in pregnancy, such as before cardiac activity is detected in the fetus or up to a certain number of weeks of pregnancy.

However, in states without abortion bans or gestational bans before 22 weeks LMP, access to abortions later in pregnancy is often limited for many reasons, including viability bans, bans on certain abortion procedures, and a limited number of abortion providers who are trained or willing to provide abortions later in pregnancy. While viability, the point when a fetus can survive outside the womb, is no longer the federal standard that defines the legality of abortion in the U.S., 16 states that still allow abortions currently have laws restricting abortion at “viability” or at 24 weeks LMP / 3^rd trimester, when viability is presumed to occur (Figure 1). These states have abortion exemptions similar to the exemptions in abortion bans (such as to preserve the health or life of the pregnant person) and gestational limits, defining when an abortion is allowed to be performed after viability. Most of the 11 states that restrict abortions at “viability” define it as the point where a physician or other healthcare provider determines whether a fetus can survive outside the womb. Four of these states include language in their abortion policies defining viability as the point where there is a likelihood that the fetus could survive without the “application of extraordinary measures” and another three states have language clarifying the fetus could survive with or without extraordinary measures.

Some states have also passed laws banning clinicians from performing certain abortion procedures that are commonly used in later abortions (Figure 2). Almost all abortions performed at or after 21 weeks are performed by a dilation and evacuation (D&E) procedure (93–95% per CDC data). This involves dilating the cervix and evacuating the pregnancy tissue using forceps, with or without suction. D&Es can be performed safely up to at least 28 weeks gestational age, and when compared to their alternative of labor induction, have been found to be quicker and result in fewer complications; further, many individuals may prefer surgical management as they will be sedated and do not have to undergo labor and delivery of the fetus.

Nebraska has enacted a D&E ban, although the state also has a 12-week gestational ban. Nine states ban dilation and extractions (D&Xs), a rarely used abortion procedure also referred to as an intact D&E or a “partial birth abortion” by policymakers (Appendix Table 1).

In addition to gestational age limits and method bans used for abortions later in pregnancy, abortions later in pregnancy are subject to the same regulations that apply to abortions earlier in pregnancy, including mandatory waiting periods and physician and hospital requirements.

How common are abortions later in pregnancy?

Abortions occurring at or after 21 weeks gestation are rare. According to the CDC’s Abortion Surveillance Data for 2021, prior to the Dobbs decision, the vast number of abortions (96%) occurred at or before 15 weeks gestation, while 3% occurred from 16 to 20 weeks gestation, and just 1% of abortions were performed at or after 21 weeks (Figure 3). This amounts to approximately 4,100 abortions per year occurring at or after 21 weeks. However, this estimate only includes the 41 reporting areas that report abortions to the CDC by gestational age and excludes major states such as California and New York. The percentage of abortions occurring at or before 13 weeks gestation has remained stable over the last few decades at 91-92%, however within this timeframe, more abortions are occurring earlier in pregnancy, at or before 9 weeks. This is likely in part due to the greater availability of medication abortions over the last two decades.

The CDC does not elaborate on the breakdown by gestational age for abortions occurring past 21 weeks, but it is likely that the vast majority occur soon after 21 weeks rather than much later in the pregnancy. While very limited contemporary data exists on this issue, a study from 1992 estimated 0.02% of all abortions occurred after 26 weeks gestation (320 to 600 cases per year).

Preliminary findings from a study on abortion provision since the Dobbs decision has found that patients living in states where abortion is banned or restricted have experienced increased delays in obtaining abortion care, in part due to arranging out-of-state travel to states where abortion is legal and limited appointment availability in abortion clinics in states where abortion is legal. Out-of-state travel for abortion services doubled in the first half of 2023 compared to the first half of 2020, likely driven by the overturning of Roe. Delays in accessing abortion services push people who want an abortion further along in their pregnancies, which could lead to an increase in the share of people who need abortions later in pregnancy.

In addition, even if patients can travel to a different state to access later abortion services, there are a few clinicians who provide abortions later in pregnancy. This was the case even before the Dobbs decision. Researchers from Advancing New Standards in Reproductive Health (ANSIRH) found that in 2023, 60 clinics provided abortions at or after 24 weeks and five clinics provided services at or after 28 weeks, meaning that most individuals in need of abortions later in pregnancy often have to travel significant distances to find an available and trained provider.¹  A University of California San Francisco study found that compared to before Dobbs there was a slight increase in the number of abortion clinics that provide abortions after 24 weeks after the Dobbs ruling. Abortions at this stage also typically require two days to complete with inpatient care, as opposed to outpatient or at-home management that is possible earlier in pregnancy. Some facilities in the U.S. perform abortions later in pregnancy as outpatient procedures (up to certain gestational ages), but it is less common than offering inpatient care for these cases.

Why do people have abortions later in pregnancy?

Individuals seek abortions later in pregnancy for a number of reasons. As part of the Turnaway study out of the University of California San Francisco, from 2008-2010 over 440 women were asked about why they experienced delays in obtaining abortion care, if any (Figure 4). Almost half of individuals who obtained an abortion after 20 weeks did not suspect they were pregnant until later in pregnancy, and other barriers to care included lack of information about where to access an abortion, transportation difficulties, lack of insurance coverage and inability to pay for the procedure. A 2022 study of patients seeking abortions later in pregnancy found that they fell into two categories: either they had learned new information about their pregnancies that made them no longer desirable, such as not finding out they were pregnant until very late in the pregnancy or the emergence of serious fetal or their own health issue; or experiencing barriers to abortion services earlier in the pregnancy that force them to delay the abortion until the third trimester.

Delays Stemming from Financial Barriers to Abortion Access: Abortions can be cost-prohibitive for many; a study examining abortion costs in 2021 found that the median out-of-pocket self-pay costs for medication abortion services was $568, $625 for first trimester procedural abortions, and $775 for second trimester procedural abortions (range $465 to $2,885). These costs do not account for lodging and transportation costs, loss of work or childcare costs, which can drive the price higher. Third trimester abortion costs can range from a couple thousand dollars to over $25,000, depending on how far along the pregnancy is and how clinically complex it is. The Federal Reserve Board found 32% of U.S. adults do not have enough in savings to pay for a $400 emergency expense, meaning many individuals may need to delay having an abortion until they can raise the necessary funds.

Fetal Anomalies: Individuals also seek abortions later in pregnancy due to medical reasons. With medical advances, many genetic fetal anomalies can be detected early in pregnancy; for example, chorionic villus sampling can diagnose Down Syndrome or cystic fibrosis as earlier as 10 weeks gestation. Structural fetal anomalies, however, are often detected much later in pregnancy. As part of routine care, a fetal anatomy scan is performed around 20 weeks, which entails ultrasound imaging of all the developing organs. Many structural anomalies are discovered at this time that would not have been apparent previously. A proportion of these are lethal fetal anomalies, meaning that the fetus will almost certainly die before or shortly after birth, meaning the fetus may be nonviable (consensus does not always exist as to which anomalies are fatal, and thus nonviable). In these cases, many individuals wish to terminate their pregnancies, rather than risk carrying the pregnancy until the fetus or newborn passes away. Very often these pregnancies are desired, making this decision exceedingly difficult for parents. Inadequate data exist to know how many abortions later in pregnancy occur due to fetal anomalies, but a study by Washington University Hospital showed almost all women whose fetuses had lethal fetal anomalies chose to terminate their pregnancies. Three (Alabama, Indiana and West Virginia) of the fourteen states with abortion bans and five states with early gestational bans (Florida, Georgia, North Carolina, South Carolina, and Utah) currently have exceptions for pregnancies with lethal fetal anomalies, but it is unknown whether any abortions under these exemptions have occurred. Among the states with viability or near viability bans, Delaware, Maryland, Massachusetts and New Hampshire have exemptions for fetal anomalies. Pregnant people who reside in states where abortion is banned and with no fetal anomaly exceptions who are unable to travel out of state can be forced to carry their pregnancies to term and deliver infants who are stillborn or die shortly after birth.

A 2011 survey of maternal fetal medicine (MFM) doctors—specialists who manage pregnancies with fetal anomalies— found most agreed that termination of pregnancy due to a lethal fetal anomaly should be allowed in all circumstances (76%). The majority (75%) discuss abortion as a management option soon after diagnosing a lethal fetal anomaly, but services for terminating pregnancies in these scenarios are limited. Even over decade before the Dobbs decision, only 40% of MFM doctors worked at healthcare centers offering abortions past 24 weeks for lethal fetal anomalies. An additional 12% knew of available services <50 miles away.

Health Risk to the Pregnant Person: Life threatening conditions may also develop later in pregnancy. These include conditions like early severe preeclampsia, newly diagnosed cancer requiring prompt treatment, and intrauterine infection (chorioamnionitis) often in conjunction with premature rupture of the amniotic sac (PPROM). If these conditions occur in a state where abortion is legal, the pregnant individual may pursue termination of pregnancy to preserve their own health. All states that ban abortion, have gestational bans, or limit abortion at or near viability, have exceptions allowing for abortions to occur when the life of the pregnant person is in danger, and 34 states have exceptions for when the health of the pregnant person is at risk (Figure 5). Former President Donald Trump reportedly supports a 16-week national abortion ban with exceptions for when the life of the pregnant person is in danger and in cases for rape or incest, but the 16-week national ban would not have an exception for when the health of the pregnant person is at risk. It is likely that a ban such as this would be structured so that it would limit abortions in states that currently permit abortions later in pregnancy, but allow states with abortion bans or gestational restrictions to keep their laws in effect.

The legal standards states use to determine when a pregnant person qualifies for a life or health exception can be ambiguous, with some standards leaving physicians in a legally vulnerable position that allow a prosecutor to bring an expert witness to contradict the physician’s medical judgment. In a recent case out of Texas, Kate Cox, a pregnant women seeking an abortion, sought a court order that would have allowed her to have an abortion under the exceptions to the Texas abortion ban. Fearing prosecution for providing abortion care that she believed it fit under the abortion ban’s exception based upon her good faith medical judgement, Ms. Cox’s physician asked a Texas District Court to determine that providing the abortion was not a violation of the state’s ban. While the District Court agreed with the plaintiffs that the case qualified for an exception, the Texas state Attorney General wrote a letter to the hospital stating that his office would still enforce the state abortion ban if abortion care was provided. Consequently, the Texas Supreme Court overruled the lower district court, finding that the physician’s “good faith belief” was insufficient to qualify for the exception, and only abortions that are certified to be necessary under the “reasonable medical judgement” standard are allowable under Texas law.

In states where abortion is banned, there have been questions and confusion about how ill a pregnant person must be for an abortion under a health exception to be performed. There are reports of patients having health complications that are not life threatening at the moment they are seeking care, and being sent home and subsequently developing serious complications that do threaten their lives as a result. In Idaho, Indiana, Tennessee, and Texas, physicians and people who were denied abortion care despite facing pregnancy complications that jeopardized their health have filed lawsuits regarding harms experienced as a result of the lack of health exceptions in their respective state abortion bans. They are asking for courts to clarify the scope of the state bans’ health exceptions and for physician judgment in making determinations about abortion as a medical treatment for emergent conditions to be granted greater deference.

In July 2022, the Department of Health and Human Services (HHS) issued guidance regarding the enforcement of EMTALA (Emergency Medical Treatment and Active Labor Act), the law that requires hospitals that take Medicare enrolled patients to perform appropriate medical screening examination to any patient who presents at the emergency department and to provide stabilizing care to patients identified as having an emergency medical condition. The 2022 guidance clarifies that hospitals and physicians have obligations to provide stabilizing care, including abortion in medically appropriate circumstances, when a patient presenting at an emergency department is experiencing an emergency medical condition. Since the guidance was issued, HHS has sued the state of Idaho for their abortion ban, which did not contain exceptions for health, and the state of Texas has sued to block enforcement of the guidance in Texas. The two federal district courts that have considered this issue have reached opposite decisions. In Texas, a federal district court blocked HHS from enforcing the EMTALA guidance in Texas and the Biden administration has appealed this decision to the 5^th Circuit Court of Appeals. In Idaho, a federal district court issued a temporary stay blocking part of the Idaho ban, which was also stayed by the 9^th Circuit Court of Appeals. However, in January 2024, the Supreme Court of the United States agreed to hear the Biden Administration’s challenge to the Idaho abortion ban and allowed Idaho’s ban to be fully in effect while the litigation is ongoing.

Have states taken action to expand access to abortions later in pregnancy?

Recognizing that access to abortions later in pregnancy can be a health preserving or life-saving medical service to a small group of pregnant people, yet very difficult to access, a few states have sought to expand access to abortions later in pregnancy. The New York Reproductive Health Act enacted in January 2019 expanded protections for abortion providers and pregnant individuals who have abortions after 24 weeks in cases of health or life endangerment or lethal fetal anomalies. In May 2023, Minnesota repealed its viability ban and in July 2023, Maine enacted L.D. 1619, allowing abortions after viability anytime a doctor deemed them medically necessary. Previously the law only allowed abortions after viability if the pregnant person’s life was in danger.

Appendix

1. Berglas NB, Schroeder R, Kaller S, Stewart C, and Upadhyay UD. Change in service availability of 2nd and 3rd trimester abortion care following Dobbs. Society of Family Planning Conference, October 2023. ↩︎

At a time when kitchen table economic problems are on voters’ minds, unexpected medical bills and health care costs top the public’s list of financial concerns, and voters who are struggling to pay their monthly bills are the most eager to hear the presidential candidates talk about economic and health care issues, the latest KFF Health Tracking Poll finds.

Nearly 3 in 4 adults say they are worried about being able to afford unexpected medical bills (74%) and the cost of health care services (73%), more than say the same about other everyday expenses, such as gas, utilities, food, and housing costs, and about paying for prescription drugs (55%). Health care worries top the list regardless of partisanship.

About half of all voters (48%) say health care costs are a major reason for their negative views of the economy, though larger shares cite everyday expenses, inflation, and housing costs. Overall, two thirds (67%) of voters view the economy negatively. Republican voters are more than twice as likely as Democratic voters to hold such negative views. 

The poll probes how people’s economic struggles color their views of the economy and their priorities for candidates. Overall, 1 in 5 adults (19%) say they have trouble affording their monthly bills, and nearly 4 in 10 (37%) say they say they can just afford their monthly bills. These groups hold very different views than those who say that they afford their bills with money left over (44% of all adults).

Those who report difficulty affording monthly bills are more likely to view the national economy negatively and are more likely to worry about affording health care and other routine expenses. They are also more likely to want the presidential candidates to talk about economic issues, including health care costs and the future of Medicaid, compared to voters who can easily afford their bills. 

The ACA Remains Popular, and More Want to Expand It Than Scale It Back or Repeal It

The poll also explores views of the Affordable Care Act (ACA), which remains popular generally, though voters again split sharply along partisan lines over what should happen to the law next. 

Most of the public (59%) views the law favorably, as has been true since Republicans’ failed attempt to repeal and replace it during President Trump’s presidency. Fewer hold unfavorable views (39%), though most Republicans do (67%).  

In addition, half (50%) of the public, including nearly a quarter of Republicans (23%), want the next president and Congress to expand what the ACA does, as President Biden has advocated. Another 16% want to keep it as is. In contrast, only about a third of the public favor either scaling back the law (14%) or repealing it entirely (18%), the options preferred by most Republicans.

While President Trump has talked about wanting to replace the ACA during his campaign, just 1 in 6 voters (16%) say that he has a plan to do so. Even among Republican voters, just 3 in 10 say that President Trump has a plan to replace the ACA.On the flip side, while the ACA was originally enacted during Biden’s tenure as vice president, just half of the public says he had either a major (21%) or minor (28%) role in its passage. Democrats ages 50 and older are most likely to say President Biden played a role in the ACA becoming law. Most adults want the law’s prohibition on insurers from denying coverage based on pre-existing medical conditions to stay. Two thirds (67%) of the public say that it is “very important” that this provision remain in place, including most Republicans (54%) However, only about 4 in 10 people (39%) are aware that that provision is part of the ACA.The poll also finds gaps in the public’s knowledge about the ACA’s impact on health coverage. While the share of adults under age 65 who are uninsured has fallen sharply since the ACA’s enactment, just over a third (35%) of the public correctly says the uninsured rate has gone down since the law’s enactment, while similar shares incorrectly say it has gone up (32%) or stayed the same (31%).

The poll findings are featured in two reports: a main report that captures the main findings on health costs, the Affordable Care Act, and the election, and a companion report that looks at differences in the economic views and priorities for adults based on their economic circumstances.

Designed and analyzed by public opinion researchers at KFF, the survey was conducted from January 30-February 7, 2024, online and by telephone among a nationally representative sample of 1,309 U.S. adults, including 1,055 registered voters. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 4 percentage points for the full sample and the registered voter sample. For results based on other subgroups, the margin of sampling error may be higher.

KFF Health News won the 2023 George Polk Award for Medical Journalism for its year-long investigation with CBS News into the failure of FDA-approved medical devices that were suspected of contributing to thousands of injuries and patient deaths.

The George Polk Awards were established in 1949 by Long Island University to commemorate George Polk, a CBS correspondent murdered in 1948 while covering the Greek Civil War. The awards place a premium on investigative and enterprising reporting that gains attention and achieves results.

The investigation, “When Medical Devices Malfunction,“ brought to light deep flaws in FDA oversight of a series of devices, including:

• Artificial knee implants that wore out prematurely;
• Metal hip implants that snapped in two and led to urgent surgeries;
• Last-resort heart pumps that may have caused or contributed to thousands of patient deaths;
• Insulin pumps that are blamed for contributing to at least a dozen patient deaths; and,
• A dental device that lawsuits alleged caused catastrophic harm to teeth and jawbones.

“This investigation revealed the deeply significant, and sometimes deadly, impact of flawed devices and oversight, and is part of our continuing work across KFF to show how people are affected by health policy,” said Dr. Drew Altman, president and chief executive officer, KFF.

“When Medical Devices Malfunction“ was reported by Fred Schulte, an investigative reporter at KFF Health News, Holly K. Hacker, the data editor at KFF Health News, Daniel Chang, the Florida correspondent at KFF Health News, Brett Kelman, a correspondent at KFF Health News, Anna Werner, the national consumer investigative correspondent at CBS News, and Nicole Keller, consumer investigative producer at CBS. It is Schulte’s and Werner’s second Polk award.

About KFF Health News’ Partnership with CBS News

The reporting in “When Medical Devices Malfunction“ was done in partnership with CBS News to investigate the safety of devices suspected of causing patient harm and explore the FDA’s process for assuring patient safety. Reporters from KFF Health News and CBS reviewed FDA data and court records and conducted many interviews with patients, device manufactures, FDA officials, consumer advocates, and others.

The investigation stems from a broader editorial partnership between CBS News and KFF Health News. The editorial partnership also features regular appearances by Dr. Céline Gounder, KFF Health News’ senior fellow and editor-at-large for public health, on CBS News, the popular “Bill of the Month” series, in which KFF Health News editor-in-chief Elisabeth Rosenthal appears regularly on “CBS Mornings” to discuss surprising medical bills, and the KFF Health News “Health Minute,” a weekly feature for CBS News Radio stations that helps millions of listeners understand how developments in health care delivery and policy affect them.

About KFF and KFF Health News

KFF is the independent source for health policy research, polling, and journalism. Our mission is to serve as a nonpartisan source of information for policymakers, the media, the health policy community, and the public. KFF Health News is a national newsroom that produces in-depth and award-winning journalism about health issues and is one of the core operating programs at KFF. Other major KFF programs include Policy Analysis; KFF Polling and Survey Research; and KFF Social Impact Media, which conducts specialized public health information campaigns. A new program on Health Misinformation and Trust is under development.

The data is available for download.

Note: For the latest information on states with approved and pending waivers to extend multi-year continuous eligibility for children, view our Section 1115 tracker “Key Themes Maps.“

The pandemic continuous enrollment provision and other research show that continuous eligibility reduces Medicaid disenrollment and “churn” rates and helps to ensure stable coverage. Guaranteeing 12-month continuous coverage for children has long been an option in Medicaid and CHIP without a waiver, but not for adults. The Consolidated Appropriations Act required all states to implement 12-month continuous eligibility for children beginning on January 1, 2024. As many Medicaid enrollees are currently experiencing disruptions in coverage as a result of the Medicaid unwinding, a number of states are pursuing strategies to help promote continuity of coverage, including through unwinding waivers and Section 1115 demonstration waivers. This Waiver Watch summarizes approved and pending Section 1115 waivers with continuous eligibility provisions for children and adults in Medicaid.

What is continuous eligibility?

States are required to provide 12-month continuous eligibility for children in Medicaid and CHIP. Continuous eligibility generally allows individuals to remain enrolled for a specific period even if there are fluctuations in income. States have long had the option to provide 12 months of continuous eligibility to children (under age 19) without a waiver, and many states (23 as of January 2023) had taken up that option for all children in Medicaid and CHIP (additional states had adopted 12-month continuous eligibility for only some children or only children in CHIP). However, the Consolidated Appropriations Act required all states to implement 12-month continuous eligibility for all children in Medicaid and CHIP beginning on January 1, 2024. Additional guidance issued on October 27, 2023 prohibits states from terminating coverage of children enrolled in CHIP for failure to pay premiums. Under the previous 12-month continuous eligibility option, states were permitted to disenroll children in CHIP during the continuous eligibility period if a family did not pay their premiums; this exception to continuous eligibility was not available in Medicaid. On February 1, 2024, the state of Florida filed a lawsuit against HHS challenging the implementation of the law, asserting states should be allowed to terminate CHIP coverage (during the 12-month period) when premium payments are not made.

Under current law, states cannot provide continuous eligibility for adults without a Section 1115 waiver submitted to the federal government. States cannot require a renewal process for Medicaid coverage for adults who are eligible based on income more than once every 12 months. While states may conduct renewals for individuals who qualify for Medicaid based on age or disability more than once every 12 months, most states conduct annual renewals for these groups. However, because states cannot guarantee continuous eligibility for adults absent a waiver, adults may lose coverage if there are “changes in circumstance,” including changes in family income, during the year. Enrollees are required to report changes in circumstances, and some states conduct periodic electronic data matches between renewal periods to identify changes in circumstance.

Continuous eligibility has been shown to reduce Medicaid disenrollment and “churn” rates. Churn occurs when individuals temporarily lose Medicaid coverage and then re-enroll within a short period of time suggesting they are experiencing short-term changes in income or difficulty completing the renewal process. When individuals churn on and off coverage, the gaps in coverage may limit access to care or lead to delays in getting needed care, which can be especially problematic for young children who receive frequent screenings and check-ups. Research has found continuous eligibility for Medicaid is associated with improved child health. While continuous eligibility increases coverage costs due to longer average eligibility periods, there are also administrative costs associated with disenrolling individuals and then subsequently processing new applications.

How are states using 1115 waivers to provide extended continuous eligibility for children?

As of February 15, 2024, three states have approved Section 1115 demonstration waivers to provide multi-year continuous eligibility to children (Table 1). Section 1115 waivers allow states to obtain federal approval to operate Medicaid programs in ways that differ from federal standards and requirements. In September 2022, CMS approved Oregon’s waiver to implement continuous eligibility for children from birth to age six as well as 24 months of continuous eligibility for nearly all enrollees ages six and older. Since then, CMS has approved multi-year continuous eligibility requests for children in Washington and New Mexico. Hawaii, Minnesota, North Carolina, and Pennsylvania have requests pending with CMS.

A number of states are developing waivers to provide multi-year continuous eligibility to children. Several states have waiver proposals under development that have recently been released for state-level public comment (California, Colorado, and New York) that include multi-year continuous eligibility for children (Table 1). Other tracking shows state activity, including legislation directing the state Medicaid agency to seek approval for multi-year continuous eligibility for children, in Illinois, Ohio and the District of Columbia. In December 2023, growing concern over loss of Medicaid coverage for children prompted federal officials to issue additional guidance with strategies to protect coverage; one strategy CMS highlighted in its guidance is providing multi-year continuous eligibility for children through Section 1115 demonstration authority.

What options do states have to provide continuous eligibility for adults?

As of February 15, 2024, five states have approved Section 1115 waivers to provide varying lengths of continuous eligibility to certain adults (Table 2). Oregon provides 24 months of continuous eligibility to nearly all enrollees over age six. New York and New Jersey provide 12-month continuous eligibility to all income-eligible Medicaid adults. Kansas provides 12-month continuous eligibility to parents and caretaker relatives. Massachusetts provides 12-month continuous eligibility for individuals following release from a correctional institution and 24-month continuous eligibility for individuals under age 65 experiencing homelessness for at least 6 months; however, the state is seeking CMS approval to expand 12-month continuous eligibility to all adults (including those eligible based on income, age, or disability status) and 24 months of continuous eligibility to all adults experiencing homelessness. Minnesota is seeking to provide 12-month continuous eligibility to young adults ages 19 and 20, and Pennsylvania is seeking to provide 12-month continuous eligibility to individuals that qualify for proposed reentry services following release from a correctional facility.

Looking Ahead

Experience during the pandemic demonstrated that continuous enrollment can ensure stable coverage and reduce churn. While increased enrollment may result in increased overall costs, the policy can also improve health outcomes and potentially lead to some longer-term savings due to less fragmented care. While the unwinding of the pandemic-era continuous enrollment provision is leading to high rates of procedural disenrollments and is expected to increase the number of people who are uninsured longer term, mandatory 12-month continuous eligibility for children as well as new continuous eligibility policies that some states are pursuing through 1115 waivers can help to provide more stable coverage once the unwinding period ends.

In this JAMA Health Forum column,  Larry Levitt, KFF’s Executive Vice President for Health Policy, explores what a second Trump presidency would mean for health care based on President Trump’s record and remarks, and concludes that a new term likely would result in efforts to weaken the Affordable Care Act, reduce federal Medicaid costs, restrict abortion access to abortion, and scale back benefits for immigrants.