News Release

What 2024 Could Bring for Working-Age Adults with Disabilities 

Published: Jan 4, 2024

As the 25th anniversary of Olmstead nears, more than one-in-10 working age adults have a disability and most do not receive public disability income. 

Over one-in-10 working-age adults reported having a disability in 2022. A disability is defined as having difficulty with hearing, vision, cognition, ambulation, self-care, or independent living, according to KFF’s examination of data on people with disabilities from the American Community Survey.

Fewer than a third of working-age adults with disabilities receive any income from social security programs, including Social Security Disability Insurance and Supplemental Security Income. Meanwhile, they are almost twice as likely to have income below 200% Federal Poverty Level compared with adults without disabilities. They are also more likely to have Medicaid and could face greater paperwork challenges during Medicaid redeterminations.

In many states, COVID-era policies that increased access to home and community-based services are ending, which may create additional barriers to care for some people with disabilities. 

As people with disabilities struggle to access and maintain the supports and services they need, average wait times for disability claims are at an all-time high and current recipients may be missing benefit payments on account of past clerical errors. 

A new proposed rule could address discrimination against people with disabilities in medical treatment and child welfare programs, establish accessibility standards for web and mobile delivery of health and human services benefits, and establish enforceable standards for accessible medical equipment. It would also codify the Olmstead court decision that requires services to be provided in the most integrated setting appropriate.

Poll Finding

Understanding the Diversity in the Asian Immigrant Experience in the U.S.: The 2023 KFF/LA Times Survey of Immigrants

Published: Jan 4, 2024

Findings

Executive Summary

Asian immigrants represent a significant and growing share of the U.S. population, contributing to the country’s communities and economy and representing dozens of countries of birth and languages spoken. Many come to the U.S. on H-1B visas, which are used by the U.S. government to employ immigrants in highly specialized and often technical fields, or on student visas for higher education. Reflecting these immigration pathways, as a broad group, Asian immigrants typically fare well on socioeconomic measures. However, contrary to the model minority myth, the experiences of Asian people in the U.S., including Asian immigrants, are not monolithic, with some subgroups facing significant socioeconomic challenges. Moreover, the U.S. has a long history of exclusionary policies focused on Asian immigrants, contributing to ongoing anti-Asian sentiment and the “perpetual foreigner” stereotype, which intensified during the COVID-19 pandemic and with some recent laws restricting the actions of Chinese immigrants in particular. Increased data on Asian immigrant experiences is important for understanding their diversity of experiences and focusing initiatives, policies, and resources to address the challenges they face.

This report examines experiences of Asian immigrant adults in the U.S. and how they vary across different factors such as region or country of origin, income, and English proficiency. It is based on The Survey of Immigrants, conducted by KFF in partnership with the Los Angeles Times during Spring 2023, the largest and most representative survey focused on immigrants living in the U.S. to date. With its sample size of 3,358 immigrant adults1 , the survey provides a deep understanding of immigrant experiences, reflecting their varied countries of origin and histories, citizenship and immigration statuses, racial and ethnic identities, and social and economic circumstances. KFF also conducted focus groups with immigrants from an array of backgrounds, which expand upon information from the survey (see Methodology for more details). Other reports from this survey include an overview report, a health and health care experiences report, and a report on politics and policy. Key takeaways from this report include:

A majority of Asian immigrants in the U.S. are from China, India, or the Philippines, are long-term U.S. residents, and are college-educated and employed; yet some face socioeconomic and language challenges. Asian immigrants include people born in China (21%), India (21%), the Philippines (17%), as well as smaller shares from other East, Southeast, South, and Central Asian countries. Three in four (74%) Asian immigrants have been in the U.S. for ten or more years and two-thirds (66%) are naturalized citizens. However, South Asian immigrants (including those from India) are more likely than East and Southeast Asian immigrants (including those from China and the Philippines) to be recent immigrants (15 vs. 7%) and less likely to be citizens (55% vs. 71%). Overall, four in ten (41%) Asian immigrants live in households with annual incomes of at least $90,000, with immigrants from South Asia (51%) more likely to have higher household incomes than immigrants from East and Southeast Asia (36%), likely reflecting differences in the shares with a college degree (71% vs. 48%). About half (49%) of Asian immigrants have limited English proficiency (LEP), including seven in ten (71%) Chinese immigrants.

Like immigrants overall, most Asian immigrants come to the US for better opportunities for themselves and their children and most feel that their lives are better as a result of coming, although they are somewhat less likely than other immigrants to say their safety is better off. Among Asian immigrants, those from China are particularly less likely to say that their safety is better as a result of immigrating to the U.S. with just one in three (34%) saying it is better as compared to at least half of Indian (52%) and Filipino (59%) immigrants. This may, in part, reflect increases in anti-Chinese sentiment during COVID-19 and recent laws targeting Chinese immigrants.

About one in three (36%) Asian immigrants report facing at least one form of discrimination or harassment in the community. These experiences include being treated worse than U.S.-born people in stores or restaurants (27%), in interactions with the police (17%), or when buying or renting a home (14%). One in five (20%) also say that the COVID-19 pandemic changed the way they are treated as an immigrant in a bad way, including about a quarter (27%) of Chinese immigrants. About four in ten (45%) with LEP also say that difficulty speaking or understanding English has made it hard for them to access health care or public assistance services or complete certain activities such as getting or keeping a job or interacting with the police.

While most Asian immigrants are faring well in employment and finances, reflecting higher educational attainment levels than other immigrant groups, those with lower household incomes face challenges. One in five (19%) living in households with lower incomes (less than $40,000 per year) have difficulty paying their bills each month, and one in three (32%) lower income Asian immigrants say they had problems paying for necessities such as housing, health care, utilities, or food in the past 12 months. Four in ten (44%) employed Asian immigrants, including half of those living in households with lower incomes, report experiencing at least one form of workplace discrimination asked about in the survey.

Reflecting their job patterns and higher incomes, a majority (64%) of Asian immigrant adults say they have private health coverage and only 4% report being uninsured. Highlighting the important role that coverage plays in access to health care, over eight in ten Asian immigrants say they have a usual source of care (86%) and a trusted doctor in the U.S. (84%) and only one in six (16%) report skipping or postponing health care for any reason in the past year. However, one in five (21%) report experiencing discrimination or unfair treatment in a health care setting due to their insurance status or ability to pay, their accent or ability to speak English, or their race, ethnicity, or skin color.

Four in ten (42%) of Asian immigrants say they don’t have enough information about U.S. immigration policies to understand how they impact their family, and many remain confused about how use of assistance for health care, housing, or food can impact immigration status. Among Asian immigrants with LEP, half (49%) say they do not have enough information about U.S. immigration policy. Seven in ten Asian immigrants, say they are unsure (55%) whether the use of non-cash benefits to help pay for health care, housing, or food can impact the likelihood of being approved for a green card or incorrectly believe this to be the case (15%). The share who incorrectly believe this to be the case is higher among noncitizens and immigrants who have been in the U.S. for less than 10 years as compared to their naturalized citizen and 10+ year resident counterparts.

Who Are Asian Immigrants?

Country/Region of Origin: One in five (21%) Asian immigrants in the U.S. are from China, an additional 17% are from the Philippines and 29% from other East and Southeast Asian countries (such as Korea, Japan, and Thailand).2  About one in five (21%) are from India with an additional 7% hailing from other South Asian countries (such as Bangladesh, Pakistan, and Sri Lanka). Asian immigrants also include those from Central Asia (including Kazakhstan, Uzbekistan, and others). See here for a list of regional groupings.

Census Region: Four in ten Asian immigrants live in the West (43%), a quarter (24%) live in the South, one in five (21%) live in the Northeast and a smaller share (12%) live in the Midwest. Almost half of Asian immigrants live in one of three U.S. states: California (31%), New York (9%), or Texas (8%).

Time in country: Similar to the overall immigrant population, most Asian immigrants are long-term U.S. residents. About three in four (74%) have lived in the U.S. for ten or more years, 14% have been in the U.S. for five to nine years, while one in ten (10%) have been in the U.S. for less than five years. Higher shares of immigrants from India have been in the U.S. for less than five years (16%) as compared to immigrants from the Philippines (6%) and this is also true for South Asian immigrants overall (15%) as compared to East and Southeast Asian immigrants (7%).

Employment: Similar to the overall immigrant population, two-thirds (64%) of Asian immigrants are currently employed for pay, including three-quarters (74%) of those ages 18-64; 17% of employed Asian immigrants are self-employed or the owner of a business.

Parental Status: About one in three (34%) Asian immigrants are the parent of a child under 18 living in their household, and the vast majority (81%) of this group say at least one of their children was born in the U.S.

English Proficiency: Similar to the total immigrant population, almost half (49%) of Asian immigrants have limited English proficiency (LEP, defined as speaking English less than very well), with shares with LEP about twice as high (71%) among immigrants from China as compared to their counterparts from India (32%) and the Philippines (34%). LEP rates are also higher among immigrants from East and Southeast Asia overall (56%) as compared to immigrants from South Asia (38%). About one in three Asian immigrants say they speak English very well (32%) and an additional one in five (19%) say they speak English exclusively. Asian immigrants speak a wide variety of languages at home, including one in five (21%) who speak some form of Chinese, one in ten (13%) who speak Filipino or Tagalog, and one in ten (10%) who speak Vietnamese. Other languages spoken by Asian immigrants include Urdu, Hindi, Korean, Japanese, and many others.

Immigration Status: Two-thirds (66%) of Asian immigrants are naturalized U.S. citizens, while about three in ten (29%) say they have a valid visa or green card, and 5% are likely undocumented. Among Asian immigrants, those from the Philippines have the highest shares (80%) of naturalized citizens followed by immigrants from China (60%); immigrants from India include lower shares of naturalized citizens (49%) which could in part be due to 16% of them being more recent immigrants (less than five years). In general, the shares of Asian immigrants who are naturalized citizens are higher among immigrants from East and Southeast Asia (71%) as compared to those from South Asia (55%).

Educational Attainment: A majority (54%) of Asian immigrants have a college degree or higher, about one in six have completed some college (18%), and about a quarter (26%) have a high school education or less. Those with a college degree or higher include much higher shares of immigrants from India (83%) as compared to immigrants from China (56%) or the Philippines (52%) and this is also true for South Asian immigrants overall (71%) as compared to East and Southeast Asian immigrants (48%).

Household Income: Four in ten (41%) Asian immigrants live in households with annual incomes of at least $90,000, and another 29% live in households with annual incomes of $40,000 to less than $90,000. About one in four (27%) live in households with lower incomes (less than $40,000 per year). Immigrants from India (62%) are much more likely to have higher household incomes compared with immigrants from China (41%) and the Philippines (37%), reflecting differences in educational attainment. Overall, immigrants from South Asia (51%) are more likely than immigrants from East or Southeast Asia (36%) to have higher household incomes.

Reasons For Coming And Life In The U.S.

Like immigrants overall, a majority of Asian immigrants cite better opportunities and a better future for their children as reasons for moving to the U.S., with high shares of immigrants from East and Southeast Asia also citing having more rights or freedoms as a reason. Among Asian immigrants, at least three in four say better economic and job opportunities (86%), educational opportunities (79%), and a better future for their children (75%) are a reason they moved to the U.S. Smaller shares say they came to the U.S. to have more rights or freedoms (66%), to join or accompany family members (51%), or to escape violent or unsafe conditions (34%). However, the share citing more rights and freedoms as a reason is higher among immigrants from East and Southeast Asia (71%) compared with those from South Asia (52%).

Majorities of Asian immigrants feel that their educational and financial situations are better as a result of moving to the US, even among those with lower incomes and those who are noncitizens (Figure 1). Overall, more than seven in ten Asian immigrants say their financial (76%) and employment (73%) situation are better, and eight in ten (82%) say their or their children’s educational opportunities are improved. Regardless of immigration status, income, or time in the U.S., a majority of Asian immigrants report they are doing better on these measures. However, the shares reporting they are doing better in terms of finances and employment are somewhat lower among noncitizens, more recent immigrants, and those with lower incomes (less than $40,000 per year) compared to their citizen, longer-term immigrant (10+ years), and higher income (at least $90,000 per year) counterparts. Moreover, those from China are less likely to say they are doing better on financial and employment measures than those from India and the Philippines.

Over Seven In Ten Asian Immigrants Say Their Finances And Education Are Better As A Result Of Moving To The U.S.

About half (54%) of Asian immigrants say their safety is better as a result of moving to the U.S.  and roughly one in five (17%) say it is worse, with those from East and Southeast Asia, noncitizens, and recent immigrants more likely to say it is worse (Figure 2). In comparison, among immigrants overall, about two in three (65%) say their safety is better as a result of immigrating. Asian immigrants from East and Southeast Asia are about twice as likely as those from South Asia to say their safety is worse (21% vs. 7%), a pattern largely driven by the one-third (33%) of immigrants from China who say this. In addition, noncitizens (26%) and recent immigrants (less than five years) (28%) are about twice as likely as naturalized citizens (12%) and longer-term immigrants (10+ years) (14%), respectively, to say that their safety is worse because of moving to the U.S. These feelings about safety may, in part, reflect the rise in anti-Asian hate incidents during the COVID-19 pandemic.

About Half Of Asian Immigrants Say Their Safety Is Better As A Result Of Moving To The U.S., Dropping To A Third Among Those From China

Eight in ten (81%) Asian immigrants, regardless of country or region of birth, citizenship status, and length of time in the country, feel that their standard of living is better than their parents’ was at their age, and six in ten (63%) feel that their children’s standard of living will be better than theirs (Figure 3). Optimism for their children’s future standard of living is higher among Asian immigrants with lower educational attainment (high school or less) (69%) and LEP (69%) compared with those who have completed college (58%) and are English proficient (57%).

Eight In Ten Asian Immigrants Feel They Are Better Off Than Their Parents, Six In Ten Feel Their Children Will Be Better Off Than Them

Experiences With Discrimination And Unfair Treatment

Like immigrants overall, a majority of Asian immigrants feel most people in their neighborhood (69%) and the state (63%) they live in are welcoming to immigrants (Figure 4). Overall, 5% say that most people in their neighborhood are not welcoming to immigrants, and about one in ten (9%) say that people in their state are not welcoming. The remaining shares say they are unsure if people in their neighborhood (26%) and state (28%) they live in are welcoming to immigrants.

Seven In Ten Asian Immigrants Feel Welcome In Their Neighborhoods And Six In Ten Feel Welcome In Their States

One in five (20%) Asian immigrants feel the COVID-19 pandemic has negatively impacted the way that they are treated as an immigrant, higher than the shares for Black (11%), Hispanic (9%), and White immigrants (7%). Immigrants from East and Southeast Asia (25%) are much more likely than those from South Asia (8%) to say that the pandemic changed how they are treated as an immigrant in a bad way, largely driven by the 27% of Chinese immigrants who say this compared with about one in ten Indian (7%) and Filipino (12%) immigrants (Figure 5). These patterns likely reflect the strong anti-Chinese rhetoric perpetuated by the Trump Administration, which repeatedly blamed China for the spread of the COVID-19 pandemic.

One In Five Asian Immigrants Feel That The COVID-19 Pandemic Negatively Impacted How They Are Treated In The U.S.

About one in three (36%) Asian immigrants say they have ever received worse treatment than U.S.-born people in stores or restaurants (27%), in interactions with the police (17%), or when buying or renting a home (14%), with those under age 65 and who are noncitizens particularly likely to report these experiences (Figure 6). Asian immigrant adults younger than 65 (38%) are more likely than their older counterparts (29%) to say they have ever experienced at least one form of worse treatment, as are noncitizen Asian immigrants (42%) compared with those who are naturalized citizens (34%).

About Four In Ten Asian Immigrants Report Ever Receiving Worse Treatment Than U.S. Born People In Certain Settings And Interactions

About three in ten Asian immigrants say they have ever experienced anti-immigrant harassment such as being told to go back to where they came from (32%) or being criticized for speaking a language other than English (29%), with higher shares of Chinese immigrants and those with LEP reporting harassment (Figure 7). About one in three East and Southeast Asian immigrants say they have ever been criticized or insulted for speaking a language other than English (34%) or were told to “go back to where you came from” (35%) compared with about one in five South Asian immigrants (17% and 22%, respectively). Chinese immigrants are more likely than Indian and Filipino immigrants to report experiencing these forms of harassment, which may in part, reflect the growth in anti-Chinese rhetoric during the COVID-19 pandemic as well as recent laws restricting actions among Chinese immigrants. In addition, Asian immigrants with LEP (34%) are more likely than their English proficient counterparts (24%) to say they were criticized for speaking a language other than English, although there are no differences in the share saying they have been told “they should go back where you came from” by English proficiency. Roughly twice as many Chinese immigrants (71%) have LEP than do Filipino (34%) or Indian (32%) immigrants, which could further explain some of the differences in experiences of harassment by country of origin.

Three In Ten Asian Immigrants Have Ever Been Criticized For Speaking A Non-English Language And Been Told To "Go Back to Where You Came From"

About four in ten (45%) Asian immigrants with LEP say that difficulty speaking or understanding English has made it hard for them to access certain services or complete certain activities, with this share rising to over half among those with LEP who also have lower educational attainment, lower incomes, or are noncitizens. About half (49%) of Asian immigrants have LEP, meaning they speak English less than very well, including 71% of immigrants from China. Among this group, about four in ten(45%) say that difficulty speaking or understanding English has ever made it hard for them to do at least one of the following: get health services (26%), get or keep a job (23%), or get help from the police (22%), apply for government help with food, housing, or health coverage (19%), or receive services in a store or restaurant (18%), (Figure 8). Among Asian immigrants with LEP, those with lower educational attainment, lower incomes (less than $40,000 per year), and who are noncitizens face disproportionate language challenges with over half of these groups experiencing at least one of these difficulties.

Asian Immigrants With Limited English Proficiency Face Language Barriers In A Variety Of Settings And Interactions

Employment and Financial Situation

Most Asian immigrants are employed, predominantly in salaried jobs. Two-thirds (64%) of Asian immigrants are employed for pay, including three-quarters (74%) of those ages 18-64. About one in five (17%) of employed Asian immigrants are self-employed or the owner of a business. Asian immigrants are more likely than immigrants overall to be salaried, with about half receiving a salary (48%), four in ten (40%) being paid an hourly rate, and one in ten (9%) being paid by the job (Figure 9). However, pay type varies starkly among Asian immigrants, largely driven by differences in educational attainment. Among Asian immigrants, those who are college graduates are about four times as likely as those with a high school diploma or less (65% vs. 17%) to be in a salaried position. Reflecting these differences, pay type also varies by region and country. For example, about eight in ten (83%) Indian immigrants have a college degree compared with about half of Chinese (56%) and Filipino (52%) immigrants, and consequently are more likely to be salaried (67% vs. 51% vs. 32%, respectively). English proficiency also makes a difference, with half of Asian immigrants with LEP working hourly jobs, compared to about one in three (32%) who are English proficient.

Roughly Half Of Employed Asian Immigrants Are Salaried

About one in five (22%) employed Asian immigrants say they are overqualified for their current jobs, that is, having more skills and education than the job requires, including about three in ten (31%) lower income Asian immigrants. Employed Asian immigrants with a college degree or higher (22%) or with some college education (33%) are more likely to feel overqualified than those with a high school education or less (9%). Similarly, those with lower incomes (less than $40,000 per year) (31%) are more likely to feel this way compared those with higher incomes (at least $90,000 per year) (18%). These data likely reflect some Asian immigrants taking jobs different from their previous work or training in their countries of origin, as described by some focus group participants.

In Their Own Words: Feelings of Being Overqualified among Asian Immigrant Focus Group Participants

In focus groups, Asian immigrants described taking jobs that required less skills and education compared to those they held in their country of birth.

“I used to work a white-collar job, now I do manual labor. My major [college course program] used to hurt my mind, now it’s my arms and legs.” – 41-year-old Vietnamese immigrant woman in Texas

“When I was in Vietnam, I owned a business, but when I moved here, I worked in a dentist’s office, I had to learn from scratch.” – 58-year-old Vietnamese immigrant woman in California

About four in ten (44%) employed Asian immigrants say they have ever experienced at least one form of workplace mistreatment in the U.S. asked about in the survey. These include being given fewer opportunities for promotion (30%), being paid less (28%), not getting paid for all the hours they worked or for overtime (15%), being given worse shifts (12%) than their U.S.-born counterparts, or being harassed or threatened in the workplace because they are an immigrant (8%) (Figure 10). The share who say they were given worse shifts or had less control over their work hours is about twice as high for lower income Asian immigrants (less than $40,000 per year) compared to their higher income counterparts (at least $90,000 per year) (17% vs. 8%).

Four In Ten Employed Asian Immigrants Say They Have Ever Experienced Some Form Of Workplace Mistreatment, Including Half Of Lower Income Asian Immigrants

Asian immigrants have higher incomes than immigrants overall, but income varies widely among subgroups in part due to variations in educational attainment. Many Asian immigrants come to the U.S. on H-1B visas, which are used by the U.S. government to employ immigrants in highly specialized and often technical fields, which has a direct impact on the types of industries Asian immigrants work in as well as on their incomes. Consequently, about four in ten (41%) Asian immigrants live in households with annual incomes of at least $90,000 and an additional one in three (29%) live in households with annual incomes of $40,000 to less than $90,000. About one in four (27%) live in households with lower incomes (less than $40,000 per year). However, income varies widely among Asian immigrants. Those from India (62%) are much more likely to have higher household income (at least $90,000 per year) compared with those from China (41%) and the Philippines (37%). Overall, immigrants from South Asia (51%) are more likely than immigrants from East or Southeast Asia (36%) to have higher household incomes (at least $90,000 per year). This pattern likely reflects differences in educational attainment as about eight in ten Indian immigrants are college graduates compared with about half of Chinese and Filipino immigrants.

Reflecting these income patterns, most Asian immigrants do not report problems paying for basic needs or monthly bills, but those with lower incomes report more financial difficulties. Most (58%) Asian immigrants say they are able to pay all their monthly bills and have some money left over, (33%) say they are just able to pay their monthly bills, and about one in ten (8%) say they have difficulty paying their bills each month. However, the share who say they have difficulty paying their monthly bills rises to about one in five (19%) among those with lower household incomes (less than $40,000 per year) (Figure 11). Similarly, one in five (20%) Asian immigrants overall say they had problems paying for necessities such as housing, food, health care, or utilities in the past 12 months, but roughly one in three (32%) of those with lower incomes (less than $40,000 per year) say this (Figure 12).

One In Ten Asian Immigrants Say They Have Difficulty Paying Their Bills Each Month, Including One In Five With Lower Incomes

One In Five Asian Immigrants Report Problems Paying For Basic Needs In The Past 12 Months

Health And Health Care Experiences

Reflecting their job patterns, a majority (64%) of Asian immigrant adults report having private health insurance coverage and only 4% report being uninsured (Figure 13). High rates of private coverage and low uninsured rates among Asian immigrant adults likely reflect their higher incomes as well as higher rates of employment in management, business, and science occupations, which are more likely to offer employer-sponsored coverage. Asian immigrants with higher educational attainment (78%), higher incomes (at least $90,000 per year) (89%), and those who are English proficient (71%), are more likely than their lower educational attainment (38%), lower income (less than $40,000 per year) (29%), and LEP (56%) counterparts to have private health coverage (Figure 14).

A Majority Of Asian Immigrant Adults Have Private Health Coverage

Rates Of Private Health Coverage Among Asian Immigrants Vary By Educational Attainment, Household Income, And English Proficiency

The large majority of Asian immigrants have a usual source of care and a trusted health care provider in the U.S. Reflecting their high rates of health coverage, roughly nine in ten (86%) Asian immigrant adults say they have a place other than an emergency room where they usually go when they are sick or need health advice, with most saying they go to a private doctor’s office (56%) and about one in five (21%) saying they use a community health center (CHC) (Figure 15). Use of CHCs as a usual source of care is higher among Asian immigrants who are noncitizens (28%) and those with LEP (25%) compared with their citizen (18%) and English proficient (18%) counterparts, reflecting their role as a national network of safety-net primary care providers serving low-income and medically underserved communities. Research shows that CHCs offer linguistically and culturally competent care to underserved racial and ethnic groups as well as people with LEP and that these services can positively impact patient satisfaction. About eight in ten Asian immigrants (84%) say they have a trusted health care provider in the U.S. However, noncitizens are less likely than citizens to say they have a trusted provider (74% vs. 90%).

Almost Nine In Ten Asian Immigrants Say They Have A Usual Source Of Care In The U.S.

Reflecting that most Asian immigrants have health coverage and a regular source of care, about one in seven (16%) say they skipped or postponed health care services in the past year, but this share rises to about three in ten (29%) among recent immigrants. (Figure 16). Chinese immigrants (21%) also are more likely than Indian (12%) and Filipino (11%) immigrants to say they went without or postponed health care even though there are no significant differences in rates of health coverage and in the shares saying they have a usual source of care by country of birth, suggesting that the differences could be driven by cultural and linguistic barriers experienced by Chinese immigrants or other unidentified factors. Overall, 6% of Asian immigrants (representing 40% of those who skipped or postponed care) say their health got worse as a result of skipping or postponing care.

More Than One In Ten Asian Immigrants Say They Have Skipped Or Postponed Health Care In The Past Year, Including Three In Ten Recent Immigrants

About one in five (21%) Asian immigrants who have sought or received health care in the U.S. say they have ever been treated unfairly by a health care provider, with those who are lower income reporting higher levels of unfair treatment than their higher income counterparts. Overall, 14% of Asian immigrants say they have ever been treated unfairly by a health care provider due to their accent or ability to speak English, 13% report unfair treatment due to their racial or ethnic background or skin color, and 11% cite unfair treatment due to their insurance status or ability to pay (Figure 17). A third (33%) of lower income (less than $40,000 per year) Asian immigrants say that they experienced discrimination or unfair treatment in a health care setting for at least one of these reasons compared with 15% of higher income (at least $90,000 per year) Asian immigrants. Asian immigrants with LEP (27%) also are more likely than their English proficient counterparts (16%) to say they experienced unfair treatment when seeking health care, including one in five (21%) who say it was due to their accent or ability to speak English.

One In Five Asian Immigrants Say They Have Ever Been Treated Unfairly In A Health Care Setting Since Coming To The U.S., Including One In Three With Lower Incomes

Confusion and Worries About Immigration Policies

While only 5% of Asian immigrants are likely undocumented, 14% of Asian immigrants overall and 26% of those who are noncitizens say they have ever worried that they or a family member could be detained or deported. Moreover, 7% of Asian immigrants overall and 11% of those who are noncitizens say immigration-related fears have led them to avoid things such as talking to the police, applying for a job, or traveling (Figure 18). Only 4% of Asian immigrants overall say they have avoided applying for a government program that helps pay for food, housing, or health care in the past 12 months because they didn’t want to draw attention to their immigration status or the immigration status of someone in their family. This could partly reflect limited need for these types of assistance given that most Asian immigrants do not report financial challenges.

A Quarter Of Asian Noncitizen Immigrants Say They Have Ever Feared Detention Or Deportation

About four in ten (42%) Asian immigrants say they do not have enough information about U.S. immigration policy to understand how it affects them or their family, with shares higher among those with lower incomes, those who have been in the U.S. fewer than five years, and those with LEP (Figure 19). About half of Asian immigrants with lower incomes (less than $40,000 per year) (52%), who have been in the U.S. for fewer than five years (55%), and with LEP (49%) say they do not have enough information about U.S. immigration policies as compared to about four in ten with higher incomes (at least $90,000 per year) (37%), who have been in the country for 10 or more years (40%), and who are English proficient (36%).

Four In Ten Asian Immigrants Say They Do Not Have Enough Information On U.S. Immigration Policy

Most Asian immigrants are uncertain about how using assistance for food, housing, and health care may affect one’s immigration status. Under longstanding U.S. policy, federal officials can deny an individual entry to the U.S. or adjustment to lawful permanent resident 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 public charge policy that newly considered the use of previously excluded noncash assistance programs for health care, food, and housing in public charge determinations. However, this policy was rescinded by the Biden Administration in 2021, meaning that the use of assistance for health care, food, and housing is not considered for public charge tests, except for long-term institutionalization at government expense. However, a majority (55%) of Asian immigrants say they are “not sure” whether use of public programs that help pay for health care, housing, or food can decrease one’s chances for green card approval and another 15% incorrectly believe this to be the case (say “yes”) (Figure 20). Among Asian immigrants, noncitizens (21%) and those who have been in the country for less than 10 years (25%) are more likely to report an incorrect understanding of the rules compared to their citizen (13%) and 10+ year (13%) immigrant counterparts.

A Majority Of Asian Immigrants Regardless Of Citizenship Status Or Length Of Time In The U.S. Say They Are "Not Sure" About Public Charge Rules

Acknowledgements

KFF would like to thank the Association of Asian Pacific Community Health Organizations, the Black Alliance for Just Immigration, Dr. May Sudhinaraset, the National Immigration Law Center, the National Resource Center for Refugees, Immigrants, and Migrants, and UnidosUS for their invaluable inputs, insights, and suggestions throughout the planning, fielding, and dissemination of this survey project.

Methodology

The KFF/LA Times Survey of Immigrants is a partnership survey conducted by KFF and the LA Times examining the U.S. immigrant experience.

The survey was conducted April 10-June 12, 2023, online, by telephone, and by mail among a nationally representative sample of 3,358 immigrants, defined as adults living in the U.S. who were born outside the U.S. and its territories. Respondents had the option to complete the survey in one of ten languages: English (n=2,435), Spanish (n=627), Chinese (n=171), Korean (n=52), Vietnamese (n=22), Portuguese (n=16), Haitian-Creole (n=13), Arabic (n=9), French (n=9), and Tagalog (n=4). These languages were chosen as they are most commonly spoken by immigrant adults from countries of focus for the survey with limited English proficiency (LEP), based on the 2021 American Community Survey (2021).

Teams from KFF and The Los Angeles Times worked together to develop the questionnaire and both organizations contributed financing for the survey. KFF researchers analyzed the data, and each organization bears the sole responsibility for the work that appears under its name. Sampling, data collection, weighting, and tabulation were managed by SSRS of Glenn Mills, Pennsylvania in collaboration with public opinion researchers at KFF.

Respondents were reached through one of three sampling modes: an address-based sample (ABS) (n=2,661); a random digit dial telephone (RDD) sample of prepaid (pay-as-you go) cell phone numbers (n=565); and callbacks to telephone numbers that that were previously randomly sampled for RDD surveys and were identified as speaking a language other than English or Spanish (n=132). Respondents from all three samples were asked to specify their country of birth and qualified for the survey if they were born outside of the U.S.

Project design was informed by a pilot study conducted from January 31-March 14, 2022 among a sample of 1,089 immigrants in collaboration with SSRS. Prior to fielding the pilot study, KFF and SSRS conducted interviews with experts who had previous experience surveying immigrants. These conversations informed decisions on sampling, modes of data collection, recruitment strategies, and languages of interviews. The pilot test measured incidence of immigrant households across four different sample types and offered a short survey in 8 different languages both online and on the telephone. Based on the results of the pilot test, the following recruitment and data collection protocol was implemented:

Sampling strategy and interview modes:

The ABS was divided into areas (strata), defined by Census tract, based on the incidence of immigrants among the population overall and by countries of origin. Within each stratum, the sample was further divided into addresses that were flagged by Marketing Systems Group (MSG) as possibly occupied by foreign-born adults and unflagged addresses. To increase the likelihood of reaching immigrant adults, strata with higher incidence of immigrant households overall, and of immigrants from certain countries of origin were oversampled.

Households in the ABS were invited to participate through multiple mail invitations: 1) an initial letter in English with a short paragraph of instructions in each of the 10 survey languages on the back; 2) a reminder postcard in English plus up to two additional languages; 3) a follow-up letter accompanied by hardcopy questionnaires in English and one additional language; and 4) a final reminder including short messages in all 10 languages. For mailings 2 and 3, additional languages were chosen by using flags to identify the language other than English likely spoken at home. Invitation letters requested the household member ages 18 or older who was born outside of the U.S. with the most recent birthday to complete the survey in one of three ways: by going online, dialing into a toll-free number, or returning the completed paper questionnaire. In addition, interviewers attempted outbound calls to telephone numbers that were matched to sampled addresses. ABS respondents completed the survey online (n=2,087), over the phone (n=105), or by mail on paper (n=469). The random sample of addresses was provided by MSG.

The RDD sample of prepaid (pay-as-you-go) cell phone numbers was obtained through MSG. The prepaid cell phone component was disproportionately stratified to effectively reach immigrants from different countries based on county-level information. To increase the likelihood of reaching immigrant adults, counties with higher incidence of immigrants overall, and of certain countries of origin were oversampled.

The callback sample included 132 respondents who were reached by calling back telephone numbers that were previously randomly sampled for SSRS RDD surveys within two years and coded by interviewers as non-English or non-Spanish speaking.  as having respondents speaking languages other than English or Spanish.

Incentives:

Initial mailings to the ABS sample included $2 as part of the invitation package, and respondents received a $10 incentive if they completed the survey in the first two weeks after the initial mailing. In order to increase participation among under-represented groups, the incentive increased to $20 for those who did not respond within the first two weeks. ABS phone respondents received this incentive via a check received by mail, paper respondents received a Visa gift card by mail, and web respondents received an electronic gift card incentive. Respondents in both phone samples received a $25 incentive via a check received by mail.

Questionnaire design and translation:

In addition to collaboration between KFF and the LA Times, input from organizations and individuals that directly serve or have expertise in issues facing immigrant populations helped shaped the questionnaire. These community representatives were offered a modest honorarium for their time and effort to review questionnaire drafts, provide input, attend meetings, and offer their expertise on dissemination of findings.

After the content of the questionnaire was largely finalized, SSRS conducted a telephone pretest in English and adjustments were made to the questionnaire. Following the English pretest, Research Support Services Inc. (RSS) translated the survey instrument from English into the nine languages outlined above and performed cognitive testing through qualitative interviews in all languages including English. The results of the cognitive testing were used to adjust questionnaire wording in all languages including English to ensure comprehension and cohesiveness across languages and modes of interview. As a final check on translation and its overlay into the web and CATI program, translators from Cetra Language Solution reviewed each question, as it appears in the program, and provided feedback. The questionnaire was revised and finalized based on this feedback.

Data quality checks:

A series of data quality checks were run on the final data. The online questionnaire included two questions designed to establish that respondents were paying attention and cases were monitored for data quality. Fifteen cases were removed from the data because they failed two or more quality checks, failed both attention check questions, or skipped over 50% of survey questions. An additional 67 interviews were removed after deemed ineligible by SSRS researchers (they were not U.S. immigrants).

Weighting:

The combined sample was weighted to adjust for the sampling design and to match the characteristics of the U.S. adult immigrant population, based on data from the Census Bureau’s 2021 American Community Survey (ACS). Weighting was done separately for each of 11 groups defined by country or region of origin (Mexico, China, Other East/Southeast Asia, South Asia, Europe, Central America, South America, Caribbean, Middle East/North Africa, Sub-Sahara Africa, all others). The samples were weighted by sex, age, education, race/ethnicity, census region, number of adults in the household, presence of children in the household, home ownership, time living in the U.S., English proficiency, and U.S. citizenship. The overall sample was also weighted to match the share of U.S. adult immigrants from each country/region of origin group. The weights take into account differences in the probability of selection for each of the three sample types. This includes adjustment for the sample design and geographic stratification, and within household probability of selection. Subgroup analysis includes data checks to ensure that the weighted demographics of subgroups are within reasonable range from benchmarks whenever possible.

The margin of sampling error including the design effect for the full sample is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

GroupN (unweighted)M.O.S.E.
Total3,358± 2 percentage points
Race/Ethnicity
Black immigrants274± 8 percentage points
Hispanic immigrants1,207± 4 percentage points
Asian immigrants1,318± 4 percentage points
White immigrants495± 6 percentage points
Immigration Status
Naturalized citizen2,134± 3 percentage points
Green card or valid visa holder819± 5 percentage points
Likely undocumented372± 6 percentage points
English Proficiency
Speaks English only or “very well”1,713± 3 percentage points
Speaks English “less than very well”1,635± 3 percentage points

Focus group methodology:

As part of this project, KFF conducted 13 focus groups with immigrant adults across the country to help inform survey questionnaire development, provide deeper insights into the experiences of immigrant groups that had a smaller sample size in the survey, and to provide a richer understanding of some of the survey findings.

Two rounds of focus groups were completed. The first round of 6 groups was conducted between September-October 2022 virtually among participants living across the country who are Hispanic immigrants (conducted in Spanish), Asian (excluding Chinese) immigrants (conducted in English), or Chinese immigrants (conducted in Mandarin Chinese). The groups were separated by gender, lasted 90 minutes, and included 5-7 participants each.

The second round of groups were conducted in-person between May-June 2023 in Los Angeles, CA and Fresno, CA with Hispanic immigrants conducted in Spanish; and in Houston, TX and Irvine, CA with Vietnamese immigrants conducted in Vietnamese. In addition, virtual groups were conducted among participants living in the Texas border region (Hispanic immigrants), the Miami, FL region (Haitian immigrants), and nationally (Black immigrants from sub-Saharan Africa). Groups were mixed gender, lasted between 90 minutes and two hours, and were conducted in English, Spanish, Vietnamese, and Haitian-Creole with 5-8 participants each.

For each group, participants were chosen based on the following criteria: Must be at least 18 years of age and have been born outside of the U.S. and its territories; for groups conducted in languages other than English, must speak English “less than very well” and be able to speak conversationally in the group’s language (i.e., Spanish). In addition, groups were chosen to represent a mix of household composition, including at least some participants who are parents; a mix of household income levels, with a preference for recruiting lower income participants; a mix of health insurance types; and a mix of immigration statuses. Goodwin Simon Strategic Research (GSSR) recruited and hosted the first round of focus groups. PerryUndem recruited and hosted the second round of focus groups. The screener questionnaire and discussion guides were developed by researchers at KFF in consultation with the firms who recruited and hosted the groups. Groups were audio and video recorded with participants’ permission. Each participant was given $150-$175 after participating.

Endnotes

  1. The sample includes 1,318 adults who self-identified as Asian or, in a small number of cases, as Pacific Islander. ↩︎
  2. Country of birth-level estimates among Asian immigrants are only available for China, India, and the Philippines due to sample size limitations. China includes Macau, Hong Kong, Taiwan, and Mongolia. ↩︎

The U.S. Government and International Family Planning & Reproductive Health Efforts

Published: Jan 2, 2024

This fact sheet does not reflect recent changes that have been implemented by the Trump administration, including a foreign aid review and restructuring. For more information, see KFF’s Overview of President Trump’s Executive Actions on Global Health.

Key Facts

  • Improving access to family planning and reproductive health (FP/RH) services globally can help prevent maternal deaths and reduce unintended pregnancies. Each year, an estimated 287,000 women die from complications during pregnancy and childbirth, almost all in low- and middle-income countries. Approximately one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception. Worldwide, 218 million women have an unmet need for modern contraception.
  • The U.S. government (U.S.) has supported global FP/RH efforts for nearly 60 years and is the largest donor to FP/RH in the world. It is also one of the largest purchasers and distributors of contraceptives internationally.
  • Over time, the U.S. role in global FP/RH has changed, sometimes influenced by differing views and political debates related to FP/RH that have arisen both domestically and internationally. Historically, these debates have concerned both the amount of U.S. funding provided as well as its use, particularly related to abortion.
  • U.S. funding for FP/RH rose steadily in its first three decades but has remained relatively flat in recent years at approximately $600 million. In FY 2023, U.S. funding totaled $608 million, including funding for the United Nations Population Fund (UNFPA). After the Trump administration withheld funding from UNFPA from FY 2017 – FY 2020, under the Kemp-Kasten Amendment, it was restored by the Biden administration in FY 2021.
  • U.S. funding for FP/RH is governed by several other legislative and policy requirements, including a legal ban on the direct use of U.S. funding overseas for abortion as a method of family planning (the Helms Amendment, which has been in place since 1973) and, when in effect, the Mexico City Policy (reinstated and expanded by President Trump as the “Protecting Life in Global Health Assistance” policy but rescinded by President Biden upon taking office).

Global Situation

Access to family planning and reproductive health (FP/RH) services is critical to the health of women and children worldwide. Improving access to FP/RH services globally can help prevent maternal deaths and reduce unintended pregnancies. Each year, approximately 287,000 women die from complications during pregnancy and childbirth, almost all in developing countries and most in sub-Saharan Africa and South and Central Asia.1  It is also estimated that approximately one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception.2 

Family Planning (FP): The ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of births.3 

Reproductive Health (RH): The state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive processes, functions, and system at all stages of life.4 

Key Factors

Key factors contributing to maternal deaths and unintended pregnancy include:5 

  • unmet need for FP services;
  • high adolescent birth rates, since adolescents (ages 15-19) are more likely to die or face complications during pregnancy and childbirth;
  • lack of access to antenatal care, which increases the risk of complications during pregnancy and childbirth; and
  • unsafe abortions, which are those performed by individuals without the necessary skills or in an unsanitary environment and often lead to complications and death.

Worldwide, 218 million women have an unmet need for modern contraception (i.e., they do not wish to get pregnant and are using no contraceptive method or a traditional method).6  Access to modern FP methods varies significantly by region. Unmet need for modern FP is highest in regions like sub-Saharan Africa, Oceania, and Western Asia where modern contraceptive prevalence is low.7  Adolescent fertility rates have declined slowly and remain particularly high in sub-Saharan Africa, where child marriage remains common, and in Latin America and the Caribbean as well as Oceania.8  While the percentage of pregnant women receiving the recommended minimum number of four antenatal care visits has been on the rise, it is 49% in the least developed countries and has reached only 54% in sub-Saharan Africa and 55% in South Asia.9  Each year, approximately 47,000 women die from complications associated with unsafe abortion.10  Access to and use of effective contraception reduces unintended pregnancies and the incidence of abortion.11 

Reasons for the lack of access to and, in some cases, utilization of FP/RH services include low awareness of the risks of sexual activity, such as pregnancy and HIV; cost; gender inequality; and laws in some countries that require women and girls to be of a certain age or have third party authorization, typically from their husband, to utilize services.12 

Interventions

FP/RH encompasses a wide range of services that have been shown to be effective in decreasing the risk of unintended pregnancies, maternal and child mortality, and other complications. These include:

  • birth spacing;
  • contraception;
  • sexuality education, information and counseling;
  • post-abortion care;
  • screening/testing for HIV and other sexually transmitted diseases (STDs);
  • repair of obstetric fistula;
  • antenatal and postnatal care;
  • genital human papillomavirus (HPV) vaccine to prevent cervical cancer and genital warts; and
  • research into new methods such as microbicides.13 

SDG 3: Achieving Universal Access to Reproductive Health

This goal, adopted in 2015 as part of Sustainable Development Goal (SDG) 3 – “ensure healthy lives and promote well-being for all at all ages,” is to “ensure universal access to sexual and reproductive health care services, including for family planning, information, and education, and the integration of reproductive health into national strategies and programmes”14  by 2030.

U.S. Government Efforts

The U.S. has a long history of engagement in international family planning and population issues, and today, the U.S. government is the largest donor to global FP/RH efforts and is one of the largest purchasers and distributors of contraceptives internationally.15  Congress first authorized research in this area in the Foreign Assistance Act of 1961.16  In 1965, the U.S. Agency for International Development (USAID) launched its first FP program and, in 1968, began purchasing contraceptives to distribute in developing countries. In the 1980s, USAID programs expanded to address maternal, newborn, and child health as well as the relationship between population, health, and the environment; and in the 1990s, USAID FP/RH programs began to recognize the need for male involvement in FP/RH and focus on the needs of young people.17  More recently, the U.S. adopted a longer term global health goal of ending preventable child and maternal deaths by 2035 and highlighted the important role of FP/RH efforts in achieving this goal.18  U.S. funding for FP/RH is governed by several legislative and policy requirements, including a legal ban on the direct use of U.S. funding overseas for abortion as a method of family planning (which has been in place since 1973) as well as more stringent restrictions in some years, such as the Mexico City Policy (see below).

Organization

USAID has long served as the lead U.S. agency for FP/RH activities, with other agencies also carrying out FP/RH activities.

USAID

USAID operates FP/RH programs in more than 30 countries, with a focused effort in 24 priority countries that are mostly in Africa and Southern Asia.19  The agency’s stated FP/RH objective is to help countries meet the FP/RH needs of their people.20  It does this by expanding sustainable access to quality voluntary FP/RH services, commodities, and information (see Table 121 ) that enhance efforts to reduce high-risk pregnancies; allow sufficient time between pregnancies; provide information, counseling, and access to condoms to prevent HIV transmission; reduce the number of abortions; support women’s rights by improving “women’s opportunities for education, employment, and full participation in society;” and stabilize population growth by advancing “individuals’ rights to decide their own family size.”22 

Table 1: U.S. Government-Funded Family Planning/Reproductive Health (FP/RH) Interventions
Addressing child marriage
Addressing gender-based violence
Biomedical and contraceptive research and development
Contraceptive supplies and their distribution
Contributions to UNFPA
Counseling and services such as birth spacing
Eliminating female genital mutilation
Financial management
Linking FP with HIV/AIDS & STD information/services
Linking FP with maternity services
Post-abortion care
Prevention and repair of obstetric fistula
Public education and marketing
Sexuality & reproductive health education
Training of health workers

Other U.S. FP/RH Efforts

Also carrying out FP/RH efforts are the Centers for Disease Control and Prevention (CDC) (research, surveillance, technical assistance, and a designated World Health Organization Collaborating Center for Reproductive Health);23  the Department of State (diplomatic and humanitarian efforts); the National Institutes of Health (NIH) (research); and the Peace Corps (volunteer activities).

Additionally, USAID’s FP/RH and maternal and child health (MCH) efforts are closely linked, although Congress directs funding to and USAID operates these programs separately. Recent years have also seen greater emphasis on coordinating FP/RH investments with global HIV efforts through the President’s Emergency Plan for AIDS Relief (PEPFAR).24  See the KFF fact sheet on U.S. MCH efforts and the KFF fact sheet on U.S. PEPFAR efforts.

Multilateral Efforts

The U.S. works with several international institutions, partnerships, and other donors to carry out FP/RH efforts. Among them are the U.N. Population Fund (UNFPA, the largest purchaser and distributor of contraceptives worldwide); Family Planning 2030 (FP2030, an international partnership to expand access to rights-based family planning services in which the U.S. is a core partner25 ); and the Global Financing Facility (GFF, a partnership to advance the health and rights of women, children, and adolescents through innovative financing, in which the U.S. is an investor and has recently enhanced its cooperation with a focus on how their combined efforts may further strengthen primary health care).26 

Funding27 

U.S. funding for FP/RH rose steadily in its first three decades28  but then declined for several years before peaking at $715 million in FY 2010. More recently, funding has been relatively flat at approximately $600 million. Total U.S. funding for FP/RH, which includes the U.S. contribution to UNFPA, was $608 million in FY 2023 (see figure for the latest information). In several years during this period, the Trump administration withheld the U.S. contribution to UNFPA (FY 2017 – FY 2020) due to the Kemp-Kasten Amendment.29  (See the KFF fact sheet on the U.S. Global Health Budget: Family Planning & Reproductive Health (FP/RH) and the KFF budget tracker for more details on historical appropriations for U.S. global FP/RH efforts.)

Most U.S. funding for FP/RH is part of the Global Health Programs account at USAID, with additional funding provided through the Economic Support Fund account. FP/RH funding is also provided through the International Organizations & Programs account at the Department of State for the U.S. contribution to UNFPA. Under current U.S. law, any U.S. funding withheld from UNFPA is to be made available to other family planning, maternal health, and reproductive health activities.30 

U.S. Funding for International Family Planning/Reproductive Health (FP/RH), FY 2016 - FY 2025

Requirements in Law and Policy31 

Legal, policy, and programmatic requirements for U.S. funding for international FP include (also see the KFF fact sheet on these and other requirements):

Helms Amendment

Since 1973, through the Helms Amendment, U.S. law has prohibited the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion.

Mexico City Policy

First instituted by President Reagan in 1984 through executive order, the Mexico City Policy (the “Global Gag Rule”) required foreign non-governmental organizations (NGOs) to certify that they would not perform or promote abortion as a method of family planning using funds from any source as a condition for receiving U.S. funding. A highly debated issue, this policy was rescinded by President Clinton, reinstated by President Bush, rescinded by President Obama, and reinstated – in an expanded form – by President Trump in January 2017. The Trump administration’s application of the policy extended to the vast majority of U.S. bilateral global health assistance, including funding for FP/RH, HIV under PEPFAR, maternal and child health, malaria, nutrition, and other programs; in past iterations, it applied to family planning assistance only, and under that administration, the policy was renamed “Protecting Life in Global Health Assistance.” The Biden administration rescinded the policy in January 2021. See the KFF explainer on the Mexico City Policy.

UNFPA & the Kemp-Kasten Amendment

Although the U.S. government helped create the U.N. Population Fund (UNFPA) in 1969 and was a leading contributor for many years, there have been several years in which funding has been withheld due to executive branch determinations that UNFPA’s activities in China violated the Kemp-Kasten Amendment, which prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization.32  The Kemp-Kasten Amendment was most recently invoked to withhold funding for UNFPA for four years (FY 2017 – FY 2020) during the Trump administration; see the KFF explainer on UNFPA funding and the Kemp-Kasten Amendment.

Voluntarism and Informed Choice

The principles of ensuring voluntary use of FP/RH services as well as informed choice of FP/RH options are specified in legislative language and program guidance.

  1. World Health Organization (WHO), et al., Trends in maternal mortality: 2000 to 2020, 2023; WHO, “Maternal mortality,” fact sheet, Feb. 22, 2023. ↩︎
  2. S. Ahmed, et al., “Maternal deaths averted by contraceptive use: an analysis of 172 countries,” The Lancet, July 14, 2012 (Vol. 30, no. 9837: 111-125). ↩︎
  3. WHO, Family Planning website, https://www.who.int/health-topics/contraception#tab=tab_1. ↩︎
  4. WHO, Reproductive Health website, https://www.who.int/teams/sexual-and-reproductive-health-and-research-(srh)/overview; International Conference on Population and Development (ICPD), Programme of Action, Cairo, 1994. ↩︎
  5. WHO, “Maternal mortality,” fact sheet, Sept. 2019; United Nations (UN), The Millennium Development Goals Report 2009, 2009; WHO, World Health Report 2005 – Making Every Mother and Child Count, 2005; Guttmacher Institute, “Unintended Pregnancy and Abortion Worldwide,” fact sheet, July 2020; WHO, “Preventing unsafe abortion,” fact sheet, Sept. 2020. ↩︎
  6. Guttmacher Institute, Adding It Up: Investing in Sexual and Reproductive Health 2019, 2020. ↩︎
  7. Oceania excludes Australia and New Zealand. U.N. Department of Economic and Social Affairs, Population Division, Estimates and Projections of Family Planning Indicators 2022: Regions, 2022. ↩︎
  8. Oceania excludes Australia and New Zealand. U.N., Progress towards the Sustainable Development Goals, Report of the Secretary-General 2023, Supplementary Information, statistical annex, undated, https://unstats.un.org/sdgs/files/report/2023/E_2023_64_Statistical_Annex_I_and_II.pdf. ↩︎
  9. UNICEF, “Table 3: Maternal and Newborn Health,” in State of the World’s Children 2023, 2023. ↩︎
  10. WHO, Unsafe abortion: global & regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 2011. See also WHO, “Abortion,” fact sheet, Nov. 2021. ↩︎
  11. Eric Zuehlke, “Reducing Unintended Pregnancy and Unsafely Performed Abortion Through Contraceptive Use,” PRB, 2009. See also WHO, “Abortion,” fact sheet, Nov. 2021. ↩︎
  12. WHO, World Health Report 2005 – Making Every Mother and Child Count, 2005. See also Guttmacher Institute, Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method, June 2016, and Guttmacher Institute, “Reasons for Unmet Need For Contraception in Developing Countries,” fact sheet, June 2016. ↩︎
  13. USAID, “Family Planning & Reproductive Health Programs – Saving Lives, Protecting the Environment, Advancing U.S. Interests,” fact sheet, undated; USAID, “Fast Facts: Family Planning,” fact sheet, Dec. 2009; WHO, Johns Hopkins, and USAID, Family Planning: A Global Handbook for Providers, 2007; USAID, Report to Congress: Global Health and Child Survival Progress Report – FY 2008, 2009; UNESCO, International Technical Guidance on Sexuality Education, Dec. 2009. ↩︎
  14. UN, Transforming our world: the 2030 Agenda for Sustainable Development, 2015. This goal was originally specified in the 1994 Cairo International Conference on Population and Development’s (ICPD) Programme of Action and was added in 2007 as a specific target of Millennium Development Goal 5 (MDG 5), which aims to improve maternal health. This addition to MDG 5 was a recognition by governments and world leaders of the need to address challenges related to access and utilization of RH services. The world did not reach this target, but some progress was made, with more women attending a health provider four times or more during pregnancy and using contraceptives, though these indicators still vary widely across regions. ICPD, Programme of Action, Cairo, 1994; UN, The Millennium Development Goals Report 2009, 2009; UN, The Millennium Development Goals Report 2015, 2015. ↩︎
  15. KFF, Mapping the Donor Landscape in Global Health: Family Planning and Reproductive Health, 2014; KFF, Donor Government Assistance for Family Planning, report series; UNFPA, Contraceptives and Condoms for Family Planning and STI & HIV Prevention (2014), 2015. ↩︎
  16. Congressional Research Service (CRS), U.S. International Family Planning Programs: Issues for Congress, Jan. 2016. ↩︎
  17. USAID, USAID Family Planning Program Timeline, undated. ↩︎
  18. USAID, “What We Do – Global Health,” webpage, https://www.usaid.gov/global-health; USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014. See also USAID, Acting on the Call 2018: A Focus on the Journey to Self-Reliance for Preventing Child and Maternal Deaths, 2018. ↩︎
  19. KFF analysis of data from the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. See also USAID, “Family Planning Countries,” webpage, https://www.usaid.gov/global-health/health-areas/family-planning/countries. Countries are selected based on high rates of unmet need for FP, prevalence of high-risk births, low contraceptive use, and significant population pressures on land and water resources (per KFF personal communication with USAID, April 2, 2010). ↩︎
  20. USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Oct. 2023. ↩︎
  21. USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Oct. 2023; U.S. Government, FY 2019 Congressional Budget Justification – Department of State, Foreign Operations, and Related Programs, 2018; USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Nov. 2017; USAID: “Family Planning and Reproductive Health,” webpage, https://www.usaid.gov/global-health/health-areas/family-planning; USAID, “Family Planning Resources,” webpage, https://www.usaid.gov/global-health/health-areas/family-planning/resources; USAID, “Reproductive Health,” webpage, https://www.usaid.gov/global-health/health-areas/reproductive-health; USAID, “Family Planning & Reproductive Health Programs – Saving Lives, Protecting the Environment, Advancing U.S. Interests,” fact sheet, undated; USAID, “Fast Facts: Family Planning,” fact sheet, Dec. 2009. ↩︎
  22. USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Oct. 2023; USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Nov. 2017; USAID: “Family Planning and Reproductive Health,” webpage, https://www.usaid.gov/global-health/health-areas/family-planning; USAID, Report to Congress: Global Health and Child Survival Progress Report – FY 2008, 2009. ↩︎
  23. CDC, Global Reproductive Health website, http://www.cdc.gov/reproductivehealth/Global/index.htm. ↩︎
  24. For example: OGAC, PEPFAR 2018 Country Operational Plan Guidance for Standard Process Countries, Jan. 28, 2018; OGAC, PEPFAR Fiscal Year 2014 Country Operational Plan (COP) Guidance, Version 2, Nov. 8, 2013; OGAC, PEPFAR Blueprint: Creating An AIDS-free Generation, Nov. 2012; OGAC, U.S. PEPFAR: Five-Year Strategy, Dec. 2009. ↩︎
  25. FP2030, “About FP2030,” webpage, https://fp2030.org/about. ↩︎
  26. The GFF was launched in 2015 as a multi-stakeholder partnership that supports country-led efforts to advance the health and rights of women, children, and adolescents, and the U.S. is as a member of the Investors Group that oversees the partnership’s overall activities. GFF, “About,” webpage, https://www.globalfinancingfacility.org/about; GFF, “Governance,” webpage, https://www.globalfinancingfacility.org/governance; GFF, “Investors Group,” webpage, https://www.globalfinancingfacility.org/governance/investors-group. ↩︎
  27. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. ↩︎
  28. PAI, Cents and Sensibility: U.S. International Family Planning Assistance from 1965 to the Present, webpage, https://pai.org/cents-and-sensibility/. ↩︎
  29. Congress has usually required that funding withheld from UNFPA be reallocated to USAID’s family planning, maternal, and reproductive health activities. See KFF, UNFPA Funding & Kemp-Kasten: An Explainer. ↩︎
  30. KFF, UNFPA Funding & Kemp-Kasten: An Explainer. ↩︎
  31. KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet; KFF, Statutory Requirements & Policies Governing U.S. Global Family Planning and Reproductive Health Efforts, brief, 2012; USAID, USAID’s Family Planning Guiding Principles and U.S. Legislative and Policy Requirements webpage, https://www.usaid.gov/global-health/about-us/policy-requirements. ↩︎
  32. CRS, The United Nations Population Fund (UNFPA): Background and U.S. Funding, May 2022; CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, Feb. 2010. ↩︎

What is the Centers for Medicare and Medicaid Services’ New AHEAD Model?

Author: Alice Burns
Published: Jan 2, 2024

In September 2023, the Centers for Medicare and Medicaid Services (CMS) announced a new opportunity for states to leverage federal funding on health care: the Advancing All-Payer Health Equity Approaches and Development (AHEAD) model. With this model, CMS–under the auspices of the CMS Innovation Center, also known as CMMI–aims to reduce the rate of growth in health care spending, improve people’s health, and reduce disparities in health outcomes. To achieve those broad aims, state demonstration programs will involve multiple programs and strategies, but the key feature of the model is prospective lump sum payments to participating hospitals that cover the costs of providing all inpatient and outpatient care to a pre-defined patient population. The lump sum payments would cover Medicaid enrollees, certain Medicare beneficiaries, and people who are covered by one or more private payers. Up to eight participating states would also be eligible for a planning grant of up to $12 million each to design and implement the model. This issue brief answers some key questions about the new model and explores considerations for potential state and private participants.

What is the AHEAD model?

The AHEAD model is an 11-year program (2024 – 2034) offering states the opportunity to leverage federal funding to make broad changes in the way health care is provided and paid for. The optional program would involve multiple payers of health care, including Medicaid, fee-for-service (FFS) Medicare, and at least one private payer. Applicants must be state agencies and include the state’s Medicaid agency, and the demonstration may be either statewide or limited to a particular region within the state. CMS developed the model to encourage and build on the successes of existing programs in Maryland, Pennsylvania, and Vermont (Box 1). AHEAD aims to limit total health spending, increase investments in primary care, change the way hospitals are paid, and connect people with increased social services that are important in supporting health. Specific components of the model include the following.

  • The AHEAD model aims to increase the percentage of health care spending that goes to primary care, and participating primary care practices will receive new care management fees to promote person-centered care. The specific mechanisms for supporting primary care will vary by state, leveraging existing Medicaid and Medicare models, but in general, participating practices will receive new funding to improve health care coordination, integrate behavioral health care, and identify and facilitate interventions to address social needs such as housing, food, and energy insecurity. Participants will be held accountable for meeting pre-specified performance targets related to quality and equity.
  • Participating states are required to recruit hospitals, but participation for hospitals within the state is voluntary. Participating hospitals would switch from being paid primarily based on the number of people served or number of services provided to a “global budget,” under which the hospitals receive a prospective, predetermined amount to provide all inpatient and outpatient care to specified patient populations. The global budgets are established using payer-specific historic spending and updated annually to account for population changes and inflation, providing hospitals with a predictable funding stream. Hospital-specific performance and equity targets will be established to deter hospitals from stinting on high-cost procedures, avoiding high-risk patients, and reducing quality.
  • To promote the model’s equity goals, participating states and hospitals must develop their own health equity plans. Health equity tools will include—at a minimum—adjusting payment rates for people’s health and social risk factors and providing hospitals with bonus payments if they meet performance targets on equity.
  • States will be accountable for limiting the growth of total health care spending within the state and are expected to leverage their legislative or regulatory authority to hold private payers accountable too. By the end of the second year, participating states must have at least one private payer participating in hospital global budgets. States may meet that requirement with participation from one or more of the following: private insurance plans, state employee health plans, Medicare Advantage (MA) plans, and others.

Box 1: What are multi-payer models and what have we learned from existing state demonstrations?

Many of CMS’ innovation strategies focus on testing new approaches to providing and paying for health care by a given payer such as Medicare or Medicaid. Multi-payer models differ in that they involve more than one payer. The AHEAD model is described as a “total cost of care” program because participating states take responsibility for the health care costs of all health care services delivered in the state or in a specified sub-state region. Three states currently have multi-payer models in place, including the following.

  • Maryland launched the first broad multi-payer model in 2014, establishing global budgets for certain hospitals, which resulted in reduced spending on hospital care per person, lower rates of readmissions, fewer hospital-acquired conditions, and improved quality of care. The current model builds on that success, including more types of providers and an increased emphasis on primary care. An evaluation in 2022 showed that the demonstration reduced acute care hospital admissions and associated spending, increased Medicare non-hospital spending, and reduced total Medicare FFS spending. The evaluation also found lower rates of preventable hospital admissions and readmissions and more timely follow-ups after hospital discharge. Maryland is currently reviewing the AHEAD model to consider whether participation in AHEAD would support continuation of its current program.
  • In 2017, Vermont implemented an All-Payer Accountable Care Organization (ACOs) model, giving providers the opportunity to participate in Medicare ACOs, which holds the voluntary network of providers accountable for the care and cost of a defined population of patients. An evaluation in 2023 showed that the growth of health care spending in Vermont for all payers was within the target range established under the model, but noted that spending growth had been affected by the COVID-19 pandemic and was therefore, not an accurate assessment of “performance.” An evaluation of quality showed improvements in many quality measures, but had similar caveats about the ability to interpret results in light of the pandemic.
  • Starting in 2019, Pennsylvania’s rural health model uses global budgets for select hospitals in rural areas to increase access to high-quality care and improve the financial viability of rural hospitals, which have faced closures in recent years. As the most recent model, there is less data available about the performance of Pennsylvania’s model, but preliminary materials show that the model improved the financial viability of participating hospitals, potentially reduced Medicare FFS spending and hospitalizations, and met performance targets for people with Medicare or private insurance.

What are the opportunities and requirements for states that participate?

The AHEAD model offers states many opportunities, but also includes many requirements, and may not be a viable option for all states. CMS describes the requirements for state, hospital, and primary care provider participants in its overview of the AHEAD model, in the frequently-asked-questions page, and in the description of the grant opportunity. Those resources summarize program goals and benefits for certain participants, but success will depend on a state’s ability to engage private parties, which in turn, face their own opportunities and requirements for participation (Table 1). AHEAD offers states the opportunity to leverage federal funding to achieve statewide improvements in health and equity while restraining total health spending, including state spending for Medicaid. But the model makes major changes to how providers are paid and requires buy-in from private entities. After the model begins, participating states, hospitals, and primary care practices will be required to meet a wide range of participant-specific performance targets with corrective action plans required for states that do not meet the specified targets.

Of the model’s requirements, hospital global budgets may be the most potentially controversial because of the significant regulatory framework they require. States must develop and implement Medicaid global budgets and may need to support global budget methodologies for other payers, including private insurers. CMS will develop and maintain a standardized methodology for Medicare FFS global budgets, but states may develop and implement state-specific systems with CMS’ approval.

Table 1: Opportunities and Requirements for AHEAD Participants(Advancing All-Payer Health Equity Approaches and Development)
States
Opportunities
  • Up to 8 states may receive up to $12 million each in federal money for planning activities and startup costs, funds will be available for up to 6 years
  • Leverage Medicare funds with greater flexibility through waivers of Medicare’s traditional payment rules
  • Improve population health and health equity
  • Reduce future Medicaid spending on high-cost hospital services
Requirements
  •  Applicants must be a state agency and must include the Medicaid program
  • Develop and administer Medicaid global budgets for hospital services
  • The state or region where the program will be effective must have at least 10,000 Medicare fee-for-service beneficiaries*
  • Hospitals and primary care practices must be willing to participate for the duration of the demonstration
  • At least one private payer must participate by year 2 of the demonstration
  • Meet state-specific performance-targets
Primary Care Providers
Opportunities
  • Increased funding for primary care
  • Ability to spend more time with patients
  • Ability to see patients achieve improved health outcomes and to address social service needs that affect health care
Requirements
  • Coordinate health care, including integration of behavioral health
  • Screen patients for health-related social needs including housing, food, and transportation; and make referrals or take other actions to address those needs
  • Collect and report patient demographic data
  • Meet performance targets related to health outcomes and equity
Hospitals
Opportunities
  • More predictable revenue
  • Ability to earn increased operating margins if able to provide more cost-effective care
Requirements
  • Accept global budget payments from Medicaid, Medicare FFS, and participating private payers
  • Take on financial risk, with potential reductions in profit margins if costs rise faster than payments
  • Collect and report patient demographic data
  • Meet performance targets related to health outcomes and equity
Private Payers
Opportunities
  • Curb the growth in spending over time by reducing the use of high-cost hospital services
  • More predictable spending on hospital services
Requirements
  • Pay hospitals’ global budgets for all covered services to all patients
  • Increase payment rates for primary care providers
*States may limit the program to certain regions, which would mean that hospitals and primary care providers in participating regions would be paid differently than in the remainder of the state. The regional model is based on Pennsylvania’s current demonstration, which only applies to select rural hospitals.

Source: KFF analysis of https://www.cms.gov/priorities/innovation/innovation-models/ahead, https://www.cms.gov/priorities/innovation/ahead/faqs, https://www.grants.gov/search-results-detail/349644, and an overview of the program during a webinar, September 18, 2023

What to watch as the model unfolds?

Will states be interested in applying when the application period opens in the spring of 2024? It is not clear whether states are interested in applying yet. The model will require significant state efforts and it is unknown whether participation will yield reduced spending or improved outcomes. Existing multi-payer models in Maryland, Pennsylvania, and Vermont have shown promising—but limited (Box 1)—results and are one of the motivations for CMS’ broader AHEAD model. (CMS has encouraged those three states to apply as a strategy to sustain their initiatives currently underway.) When states submit their applications, they select one of three cohorts to participate in, with cohorts having rolling start dates to being their planning, and eventually, implementation activities. Timing will depend on the cohort, but in general, planning activities will occur between July 2024 and December 2026 and implementation will occur between January 2026 and January 2027. The models will run through the end of 2034.

Will states be able to engage employers and private insurers to meet the goal of restraining the growth in spending on health care? The AHEAD model only requires one private payer to participate in hospital global budgets, and that requirement may be met by participation from a MA or state employee plan, among others. However, states may have difficulty meeting spending targets in the absence of meaningful participation from private payers. To measure performance in curbing spending growth, CMS will develop projected growth rates for Medicare and all-payer health care spending using state-specific historical spending data. States will be held responsible for keeping actual spending by Medicare FFS and all payers below those projected growth rates. States may use their legal authority to compel participation or other changes among private insurers, but that approach could create political resistance. Further, states do not have legal authority over employer plans in which the employer pays some or all costs directly from their own funds (e.g., self-funded plans). Therefore, achieving buy-in from all payers will require models that private payers and employers see as advantageous and opt to join.

Will states with significant enrollment in Medicaid managed care or MA elect to participate? States with significant enrollment in Medicaid managed care organizations (MCOs) or MA will need to engage those plans to meet spending targets. Significant use of Medicaid MCOs or enrollment in MA does not preclude participation in the model but will require states to partner with the private plans delivering services if the state is to meet overall spending targets. (Applicants will also need to make sure they have at least 10,000 Medicare beneficiaries enrolled in Medicare’s FFS program.) Maryland and Pennsylvania are useful examples for states to consider if they are interested in AHEAD and have significant MCO or MA enrollment because CMS has modeled the program after their demonstrations and encouraged both states to apply. The two states rely heavily on MCOs to provide Medicaid services: 85% of enrollees in Maryland and 92% in Pennsylvania are enrolled in Medicaid managed care. Both states also have measurable enrollment in MA, although, Maryland’s rate is lower than that of most states: 52% in Pennsylvania and 24% of Medicare beneficiaries in Maryland are enrolled in MA.

What types of hospitals will be able to participate most easily? For hospitals, the shift from emergent and inpatient hospital care to primary and outpatient care could mean forgone revenues from high-cost services. Hospitals that have already acquired primary care practices may be keener to participate as forgone revenues would be replaced with increased payments for primary care. In states where participating hospitals have already acquired a greater share of the region’s outpatient practices, the global budgets will capture a larger percentage of overall health care spending.

Could AHEAD encourage hospitals to acquire additional physician practices (vertical consolidation)? The AHEAD model only applies to services that are provided by participating hospitals and primary care providers. If the model spurs additional vertical consolidation (such as hospitals buying new specialty groups), a bigger share of health care spending would fall under the model’s global budgets. Previous research shows that vertical consolidation often results in higher prices without any corresponding gains in quality. However, the AHEAD model’s global hospital budgets will be set to limit the growth of health care spending. To the extent that vertical consolidation increases in AHEAD states and regions, private payers may be encouraged to participate in hopes of limiting their cost increases stemming from higher prices for vertically integrated systems.

How will CMS evaluate improvements in population health, equity, and the quality of care? The AHEAD model’s goals—lower health care spending, improved population health and health equity, and higher-quality care—may in some cases be in conflict; and CMS has included a multi-faced quality and population health strategy to ensure that reduced spending does not result in inferior health-related outcomes. Key to measuring outcomes will be enhanced demographic data collection, which requires participating hospitals and primary care practices to collect and report self-reported patient demographic data. Under the quality and population health strategy (Appendix X in the grant application materials), participating states, hospitals, and primary care providers will be evaluated on outcomes related to population health and the quality of care. Measures will be evaluated for subpopulations using demographic data to address health disparities within the state. Participating states and providers will be required to meet overall targets and targets for sub-populations. Specific sub-populations are not enumerated in the grant materials, but they will be defined based on currently observed health disparities.

Given the broad range of quality measures participants must meet, will there be sufficient providers and social resources for participants to meet those goals? States will be required to select at least one quality measure from the following categories: population health (measures will be drawn from the Behavioral Risk Factor Surveillance System), prevention and wellness (e.g., cancer screening), chronic conditions (e.g., management of high blood pressure or diabetes), behavioral health (e.g., treatment of opioid use disorder or depression), quality of care (e.g., hospital readmissions), and other measures (maternal health, preventive care, or social drivers of health). The quality and population health strategy will include people’s experiences with care, including outcomes from the Hospital Consumer Assessment of Healthcare Providers and Systems survey. For states to improve population health across all dimensions, people will need access to health care and in some cases, assistance with social needs such as housing, food, and energy insecurity. While it is accepted that access to housing, food, and energy has a direct impact on health, health programs have traditionally had a limited role in addressing those issues. For example, Medicaid managed care plans may screen for unmet needs, refer people to services, and work with community-based organizations to provide access to assistance, but few plans directly deliver the services or track outcomes. Recent guidance has expanded opportunities for states to use Medicaid to address social needs. Recognizing that many people have insufficient access to housing, food, and energy assistance, states may find that increasing Medicaid’s role in providing such assistance supports meeting the broad goals enumerated under the AHEAD model.

Employer Health Benefits Annual Survey Archives

Published: Jan 1, 2024

KFF has conducted this annual survey since 1999. The archives include surveys conducted in partnership with the Health Research and Education Trust through 2017 and a small business supplement of the 1998 survey conducted by KFF. The survey was previously conducted by KPMG from 1991–1998 and the Health Insurance Association from 1987–1991. The survey, which is traditionally released each Fall, tracks trends in employer health insurance coverage, the cost of that coverage, and other topical health insurance issues. Findings are based on a nationally representative survey of public and private employers with three or more employees, including those who respond to the full survey and those who indicate only whether or not they provide health coverage.

2023 | 2022 | 2021 | 2020 | 2019 20182017 | 2016 2015 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | 2005 | 2004 | 2003 | 2002 | 2001 | 2000 | 1999 | 1998 |

2023Full Report (.pdf)

2022Full Report (.pdf)

2021Full Report (.pdf)2020Full Report (.pdf)

2019Full Report (.pdf)

2018Full Report (.pdf)

2017Full Report (.pdf)

2016Full Report (.pdf)

2015Full Report (.pdf)

2014Full Report (.pdf)2013Full Report (.pdf)2012Full Report (.pdf)

NOTE: In 2011, our methodology for calculating employer weights was updated.  Statistics such as the percentage of firms offering health benefits or the percentage of firms offering retiree coverage are updated in the preceding reports.  Statistics based on the percentage of covered workers were not affected by this change.  Most changes were not statistically different.  For more information, see the Survey Design and Methods Section in the 2011 Report.

2011

Full Report (.pdf)2010

Full Report (.pdf)2009

Full Report (.pdf)2008

Full Report (.pdf)2007

Full Report (.pdf)2006

Full Report (.pdf)2005

Full Report (.pdf)2004

Full Report (.pdf)2003

Full Report (.pdf)

NOTE: In 2003, our methodology for calculating weights was updated. New estimates for many statistics published in 1999-2002 are available in the preceding reports.  Most changes were not statistically different.  For more information, see the Survey Design and Methods Section in the 2003 Report.

2002

Full Report (.pdf)2001

Full Report (.pdf)2000

Full Report (.pdf)1999

Full Report (.pdf)1998

Full Report (.pdf)

Year in Review: 10 Health Policy Issues for 2023

Published: Dec 22, 2023

Here’s a look back at 10 issues KFF tracked closely this year with some of our top findings summarized:

Health care costs continue to be a burden for many Americans: From our data showing that family health insurance premiums for employer coverage rose 7% to nearly $24,000 this year—and became unaffordable for many workers at small employers — to our series on “Dying Broke” focused on how older Americans struggle to pay for long-term care—the health care affordability crisis continues to plague Americans and remain a top issue going into the 2024 election. And, while anti-obesity drugs captured a lot of attention, coverage, cost, and access is unclear. More than 100 million people in America—41% of adults—have medical bills they can’t pay.

Access to Abortion and contraception remained top issues for voters following the Supreme Court’s decision to overturn Roe v. Wade last year. We tracked state abortion policies and litigation throughout the year, and also explored the right to contraception across the U.S. Our newsroom dove into how the issue is playing out nationally and in the states. Abortion also played a role in Congressional discussions about reauthorizing PEPFAR, the U.S.’ signature program to provide HIV prevention and treatment services to millions, saving more than 25 million lives over 20 years.

Medicaid enrollment began to dip, with further drops expected. Our annual survey of state Medicaid directors found that states expect national Medicaid enrollment will decline by 8.6% in state fiscal year 2024 as state Medicaid agencies continue to unwind pandemic-related continuous enrollment protections. As of Dec. 13, more than 12 million people have been disenrolled from Medicaid due to unwinding. Some subsequently regained coverage, so the net enrollment decline will be lower. At the same time, North Carolina just this month expanded their Medicaid programs to cover low-income adults, joining 39 other states and the District of Columbia.

Medicare drug price negotiations began, which were authorized as part of last year’s Inflation Reduction Act, but with significant debate by the drug industry. Medicare open enrollment concluded on Dec. 7, and we heard from Medicare beneficiaries about their views on marketing practices, looking for options, and their coverage. Many seniors let their plans renew automatically.

Covid was still a thing but Americans began to worry less about the pandemic, and their chances of getting sick, as our COVID-19 Vaccine Monitor showed. Interest in getting the latest booster waned even though most Black and Hispanic adults expected to get it while most White adults did not. Plus, following the end of the public health emergency declaration in May, finding a booster and paying for it was confusing for many, prompting a “cheat sheet” to help figure it out.

Misinformation continued to be prevalent across health issues, and KFF found that at least four-in-10 people say they’ve heard each of 10 specific false claims but relatively few believe those claims are definitely true. Most are simply uncertainty, which creates a “muddled middle,” that can be reached with reliable information from trusted sources, such as doctors and local television news.

Advancing health equity remains a top issue for health policy experts and researchers. New survey research from KFF showed that six-in-10 Black adults, about half of American Indian and Alaska Native and Hispanic adults, and four-in-10 Asian adults say they prepare for possible insults from providers or staff and/or feel they must be very careful about their appearance to be treated fairly during health care visits at least some of the time. KFF Health News also continued its coverage of how health outcomes differ based on race and ethnicity.

Everything old is new again? And, to close out the year, we heard from former President Trump and Gov. Ron DeSantis (R-FL), that they want to replace or alter the Affordable Care Act (ACA). KFF’s polling shows that Americans broadly support the ACA, with more than twice the share of Democratic voters (70%) than Republican voters (32%) saying it’s a very important issue for the candidates to discuss. Plus, there’s been record enrollment in the ACA marketplace this year. KFF Health News explored the issues in its “What the Health” podcast episode and in its summary of related media coverage.  

What are the Recent Trends in Employer-Based Health Coverage?

Authors: Gary Claxton and Matthew Rae
Published: Dec 22, 2023

Employer-sponsored health insurance (ESI) is the largest source of health coverage for non-elderly people, covering 60.4% of this population in March 2023. Not all workers have access to ESI, however; some workers are in jobs where the employer does not offer coverage (usually smaller employers) and some workers are not eligible for the coverage offered at their job. Additionally, some workers do not enroll in the ESI they are offered.

This chart collection presents analysis of data from recent Annual Economic and Social (March) Supplements (ASEC) of the Current Population Survey (CPS) to examine who among non-elderly people has ESI and which workers are offered and eligible for coverage at their current jobs.

The analysis of part of the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

News Release

Lower-Income People with Employer Coverage are More Likely to Report Negative Outcomes Due to Insurance Problems Than Their Higher-Income Peers

Published: Dec 19, 2023

Lower-income adults with employer coverage are more likely than their higher-income peers to report negative outcomes due to problems using their insurance, a new KFF analysis shows.

Drawing on data from the KFF Survey of Consumer Experiences with Health Insurance, the analysis shows that similar shares of lower- and higher-income adults with employer coverage report having common problems with their insurance such as denied claims or prior authorization issues.

At the same time, those with lower incomes are more likely than their higher-income peers to say they suffered adverse consequences due to insurance problems. This includes experiencing a significant delay in getting needed care or being unable to get recommended medical treatment. In addition, nearly three times as many of those with lower incomes report suffering a moderate or serious decline in their health compared to those with higher incomes.

In addition, about three-in-10 people with employer coverage also say that they had problems paying for medical care in the past year (31%), more than double the share among those with higher incomes (13%).

The analysis also examines differences among lower- and higher-income adults with employer coverage in their satisfaction with their coverage and plan’s provider networks, and in the ease of signing up and comparing their coverage options.

Lower Income Adults with Employer Sponsored Insurance Face Unique Challenges with Coverage Compared to Higher Income Adults

Published: Dec 19, 2023

The KFF Consumer Survey assessed consumers’ experiences with their health insurance coverage, their understanding of their coverage, problems they may face with their insurance, and if they believe that their insurance coverage is adequately meeting their needs. This Data Note examines the experiences of lower income adults with their current employer sponsored insurance (ESI) — including their reported satisfaction with the costs, quality, and availability of network providers — in comparison to higher income adults with ESI coverage. Lower income adults in our survey were defined as adults with reported household incomes below 200% the federal poverty line (FPL). This is any income below $27,180 for a single adult or $46,060 for a family of three. Higher income adults are defined as those with household incomes at or above 200% of FPL. Lower income adults with ESI were as likely to report insurance problems as higher income adults with ESI. However, lower income adults with ESI were more likely to report problems paying for health care, delayed treatment, and a decline in health as a result of insurance problems. Lower income adults with ESI were also more likely to say the availability and quality of health care professionals covered by their insurance was fair or poor, and were more likely to report difficulty in signing up for coverage and comparing options.

Lower income adults with ESI were more likely to report problems paying for health care services compared to higher income adults.

Among those with ESI coverage, lower income adults (31%) were over twice as likely to report trouble paying for medical bills compared to higher income adults (13%).

Lower Income Adults With ESI Were More Likely To Report Problems Paying For Medical Care

Lower income adults with ESI were just as likely to report insurance problems as higher income adults with ESI, but were more likely to delay treatment and report a decline in health as a result of insurance problems.

Lower income adults with ESI were as likely as higher income adults with ESI to report having common problems with their insurance over the past year, such as prior authorization issues (16% for lower income adults and 15% for higher income adults) and denied claims (22% for lower income adults and 21% for higher income adults). However, lower income adults were more likely than higher income adults to report negative outcomes as a result of experiencing insurance problems. Among those with ESI who had a problem with their current insurance in the past year, lower income adults were more likely to report a significant delay in treatment or care (26%) as a result of insurance problems compared to higher income adults (14%). Additionally, one in four lower income adults reported being unable to receive medical treatment recommended by a medical provider as a direct result of the problems they had with their current health insurance, compared to 13% of higher income adults. Lower income adults were also more likely to report a moderate to serious decline in health as a result of insurance problems compared to those with higher income. Over twice as many lower income adults (30%) reported a moderate or serious decline in health as a direct result of insurance problems compared to higher income adults (11%).

Lower Income Adults With ESI Were More To Likely Experience Negative Outcomes As A Result Of Insurance Problems

Lower income adults with ESI were more likely to rate the availability and quality of providers within their network as “fair or poor.”

Lower income adults with ESI were more likely to rate the overall performance of their current health insurance as “fair” or “poor” (31%) compared to higher income adults with ESI (17%). Additionally, lower income adults with ESI were more likely to grade the availability and quality of in-network providers within their health insurance as fair or poor overall compared to adults with higher incomes. About a quarter (23%) of lower income adults with ESI rated the availability of health care professionals covered by their insurance as “fair” or “poor,” compared to about one in eight (13%) of adults with higher incomes. In addition, one in five (21%) lower income adults rated the quality of health care professionals covered by their insurance as “fair” or “poor” compared to one in seven (14%) higher income adults. A quarter of lower income adults with ESI also gave fair or poor ratings on the availability of mental health professionals covered by their health insurance.

Lower Income Adults With ESI Were More Dissatisfied With The Availability And Quality Of Medical Providers Covered By Insurance Compared To Higher Income Adults With ESI

Lower income adults with ESI reported more difficulty in signing up for coverage and comparing plans compared to higher income adults with ESI.

Lower income adults with ESI (20%) were twice as likely to state that the application process for insurance was somewhat or very difficult compared to higher income adults (10%). Additionally, three in ten (29%) lower income adults reported more difficulty in comparing the monthly premium among insurance options, compared to 17% of those with higher incomes. Lower income adults were also twice as likely to report difficulty finding a health plan that met their needs (29%) than higher income adults (14%).

Lower Income Adults With ESI Reported More Difficulty In Signing Up For Coverage And Comparing Plans Compared To Higher Income Adults With ESI.

Discussion

Lower income adults face unique financial barriers to health care that could negatively affect their health outcomes. Lower income adults with ESI in our survey were much more likely to report financial difficulties in paying for medical bills, aligning with past research that shows lower income adults tend to spend a higher share of their income on health care costs compared to higher income adults. Many lower income adults do not have a safety net or savings to pay for medical costs and are disproportionately burdened by medical debt. High health care costs may deter lower income adults with ESI from seeking the medical care they need, leading to worse health outcomes. Lower income adults often cannot afford to lose income to see their health care provider if their job does not offer enough sick leave or paid time off, which could also lead to worse health outcomes down the line. Some lower income individuals are denied care due to outstanding medical bills, which could worsen any illness or condition that they have. Additionally, lower income adults are more likely to be exposed to occupational hazards within the workplace that can lead to injury or disease, which could also lead to unexpected, pricy medical costs or a reduction in wages.

Some lower income adults with ESI may end up paying more for “affordable” insurance through their employer than they would pay for other types of coverage. For example, some lower income adults are eligible for cost-sharing reductions and premium assistance that would greatly lower the percentage of monthly income they would be expected to contribute towards their monthly premium (as low as 0 to 2% for those with incomes less than 200% FPL) for a Marketplace plan, but cannot take advantage of this financial assistance if the employer plan they are being offered meets an affordability threshold under by the ACA (a premium contribution of 8.39% of income for 2024). Additionally, adults who are eligible for Medicaid or state premium assistance programs in their state would typically face lower out-of-pocket spending with these coverage types compared to if they enrolled in ESI coverage, although these options may not available to single adults who live in states that did not expand Medicaid or have not established a state premium assistance program.

Nearly six in ten employers reported that they have a moderate or high level of concern regarding cost-sharing for their employees. Some employers have attempted to reduce health care costs for adults with ESI, specifically for those with lower incomes, through use of different health care plan designs such as:

  • Salary based premium programs: These are programs that base the monthly premium amount an enrollee is expected to pay on their annual salary. Salary-based premium programs lower monthly premium costs but may not contain costs for other out-of-pocket expenses like deductibles.
  • Co-pay plans: These plans offer flat fees for routine doctor visits and typically have low deductibles. Co-pay plans may be beneficial for those who use insurance primarily for routine visits, but may also be financially burdensome for those who need care outside of routine health care services, as these may lead to higher health care costs.
  • High deductible health plans (HDHPs): These are health plans that have higher deductibles but low premium costs. HDHPs are typically beneficial for those who can contribute or meet the deductible by enrolling in a Health Savings Account (HSA), a benefit sometimes offered to those enrolled in HDHPs where they can set aside money on a pre-tax basis to pay for out-of-pocket healthcare costs or a Health Reimbursement Account (HRA) where ESI enrollees can be reimbursed for paying for certain medical expenses. Lower income adults with ESI sometimes do not have enough money to meet the deductible, even when a savings option such as an HSA or HRA is available. In addition, tax-preferred HSAs and HRAs are of less value to lower income people in lower tax brackets.

Uptake of health plans designed to lower cost-sharing for ESI enrollees is unknown. Ten percent of large firms reported implementing a program that lowers premium costs for lower income enrollees, and five percent offered programs that help lower cost sharing for lower income enrollees overall. One brokerage firm survey found that 39% of employers surveyed offered co-pay plans to their enrollees, and 19% offered a salary based premium program.

Lower income adults with ESI reported more problems in accessing timely and quality behavioral health services compared to higher income adults with ESI. Ensuring timely and adequate access to behavioral health care is an issue for those with ESI coverage, but the survey findings indicate that this may be an even bigger problem for lower income adults with ESI, who are more likely than their higher income counterparts to rate their insurance coverage negatively in terms of the availability of mental health providers. It is not clear whether lower income adults with ESI are more challenged by time and distance to in-network providers, lack of available appointments, high demand, difficulties in accessing providers using public transportation or other issues, such as fewer providers regardless of in-network status who they trust with their care. Studies have shown that many individuals with employer coverage must access behavioral health care through out-of-network providers, paying the higher out-of-network rates or paying the entire cost of the care. This may simply not be an option for a lower income adult with the same ESI coverage. Also, lower income adults with ESI may be more likely to choose an ESI coverage option with a narrower network than other available plan options because it is the lowest cost option available. Proposed updates to the Mental Health Parity and Addiction Equity Act would require health plans, including employer-sponsored plans, to collect and evaluate information related to the status and breadth of their behavioral health networks, including utilization of out-of-network behavioral health.

Lower income adults reported that they were more likely to experience difficulty in signing up for coverage and this could lead to worse health outcomes and medical debt. Lower income respondents with ESI in our survey were more likely than those with higher incomes to report having a difficult time comparing plan options and signing up for coverage that best met their needs. This could be related to more complex needs, as well as lower levels of education. Signing up for coverage and comparing options can be complicated for consumers. While Human Resources (HR) departments can be helpful, HR professionals, especially those working in small firms, might not always have the time or expertise needed to assist employees. Also, signing up for coverage can also be especially challenging for those who are eligible for coverage options outside of ESI (e.g., adults who are eligible for Medicaid in their state) or for consumers who are switching to ESI coverage as a result of the unwinding of the Medicaid continuous enrollment requirement and must navigate complications that come with the ESI enrollment process, such as enrolling in coverage in alignment with special enrollment period deadlines.

It may be difficult for lower income adults with ESI to find assistance outside of Human Resources that will help them with the enrollment process, including comparing available choices between ESI and public programs. Insurance brokers might provide assistance for those eligible for Marketplace coverage, but, according to a 2022 KFF Assister survey, brokers were less likely than other assisters to provide help with Medicaid enrollment, and did not always have the same ability to work with those who needed language assistance.  There is no longer any federally supported program that is designed to offer resources to those with ESI as there was under the Consumer Assistance Program (CAP). CAP was established under the ACA and offered federal funding for states to create programs to assist consumers with insurance problems and identify their best options for health coverage. Unlike the Navigator program that was specifically created to assist Marketplace, Medicaid, and CHIP consumers, the CAP program was able to assist consumers with ESI coverage as well as those with other types of coverage, for those states that chose to participate. 35 states and the District of Columbia signed up for CAP in 2010, but the grant was not renewed for federal funding, eliminating the only federally funded program that could assist those with ESI coverage. Many states have continued their CAP programs through their own funding, but others have discontinued their operations.

Methodology

This KFF Survey of Consumer Experiences with Health Insurance was designed and analyzed by public opinion researchers at KFF. The survey was designed to reach a representative sample of insured adults in the U.S. The survey was conducted February 21–March 14, 2023, online and by telephone among a nationally representative sample of 3,605 U.S. adults who have employer sponsored insurance plans (978), Medicaid (815), Medicare (885), Marketplace plans (880), or a Military plan (47).

The margin of sampling error for adults with employer-sponsored insurance is plus or minus 4 percentage points. For the 213 adults with employer-sponsored insurance with a household income under 200% of the federal poverty line the margin of error is plus or minus 8 percentage points. For the 758 adults with employer-sponsored plans and household incomes of 200% of the federal poverty line or greater, the margin of sampling error is plus or minus 4 percentage points.

The sample includes 2,595 insured adults reached through the SSRS Opinion Panel either online or over the phone (n=75 in Spanish). Another 504 respondents were reached online through the Ipsos Knowledge Panel. Another 289 (n=10 in Spanish) interviews were conducted from a random digit dial (RDD) of prepaid cell phone numbers (n=190) and landline telephone numbers (n=99). An additional 217 respondents were reached by calling back respondents who said they were insured in previous KFF probability-based polls.

Respondents were weighted separately to match each group’s demographics using data from the 2021 American Community Survey (ACS). Weighting parameters included gender, age, education, race/ethnicity, and region.

For full details on the survey methodology, see the Methodology tab of the KFF Survey of Consumer Experiences with Health Insurance.

This work was supported in part by a grant from the Robert Wood Johnson Foundation. The views and analysis contained here do not necessarily reflect the views of the Foundation. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

An Update on ACA Medicaid Expansion: What to Watch in North Carolina and Beyond

Published: Dec 18, 2023

North Carolina started implementation of the ACA Medicaid expansion on December 1, 2023, after becoming the 41st state to adopt the Affordable Care Act (ACA) Medicaid expansion when Governor Roy Cooper signed legislation earlier this year. Expansion will be implemented in conjunction with other major delivery system reforms and activities to address social determinants of health and reduce disparities. North Carolina is the first state since Virginia in 2018 to adopt Medicaid expansion through a legislative process; the last six states after Virginia (Idaho, Missouri, Nebraska, Oklahoma, South Dakota, and Utah) adopted expansion through ballot initiatives. North Carolina is the largest state since Pennsylvania in 2015 to expand Medicaid.

As North Carolina starts implementation of the ACA Medicaid expansion, CMS under the Biden administration urges the 10 remaining non-expansion states to adopt the ACA Medicaid expansion, though the administration has little power to encourage expansion. At the same time, former President Trump announced he would renew efforts to replace the ACA if elected again, which could put coverage and financing under the Medicaid expansion at risk. If all remaining states adopted the Medicaid expansion, approximately 3.5 million uninsured adults would become newly eligible for Medicaid. This policy watch examines implications for expansion in North Carolina as well as key issues to watch in North Carolina and across other states.

How many adults could be covered under Medicaid expansion in North Carolina?

An estimated 600,000 adults are newly eligible for full Medicaid coverage under the Medicaid expansion. Coverage expanded to nearly all nonelderly adults with incomes up to 138% of the Federal Poverty Level (FPL) ($34,307 for a family of three in 2023) on December 1 in North Carolina. Prior to expansion, North Carolina Medicaid income eligibility limits were 37% FPL for parents ($9,198 for a family of three in 2023) and 0% for other adults. KFF estimates that 173,000 uninsured adults fell into the coverage gap (because they had income above Medicaid limits but below poverty and were therefore not eligible for premium subsidies in the ACA Marketplace). Recent estimates from the state show that the 600,000 people eligible under expansion include 200,000 individuals not currently enrolled in Medicaid, 300,000 individuals who were enrolled in family planning-only benefits (which provides enrollees limited coverage of reproductive health services), and 100,000 individuals who may have lost full Medicaid coverage in the absence of expansion as the state resumed redeterminations due to the unwinding of the continuous enrollment provision. In November, individuals in family planning coverage were automatically moved to full coverage to be able to receive full coverage on December 1.

North Carolina is using an array of communication and outreach strategies to help enroll eligible individuals in expansion. The state is working with community partners to help people get enrolled in coverage. In October, the North Carolina Department of Health and Human Services launched a new website with basic information about expansion including who is eligible, what benefits are covered, and how to apply, as well as a toolkit of English- and Spanish-language resources for providers and organizations to conduct outreach about the state’s expansion of Medicaid. The toolkit includes flyers, social media graphics and posts, a video on how to apply for coverage online, and other resources. The state is also providing outreach training, volunteer opportunities, and other tools, such as deliveries of printed materials for people who want to conduct outreach in their communities. In November, the state started sending text messages, phone calls, and emails to notify up to 300,000 Family Planning program enrollees about their automatic enrollment in full coverage.

What factors contributed to North Carolina expanding Medicaid?

Expansion had longstanding support from Governor Cooper but took a few years to gain consensus in the state legislature. In prior years, Cooper proposed Medicaid expansion in his state budget proposals; however, the Republican-controlled legislature did not include expansion in the final budgets. In 2019, debate over Medicaid expansion resulted in a budget impasse. In 2021, the budget omitted expansion but established a legislative committee to study Medicaid expansion. In 2022, both chambers of the legislature, under Republican leadership and with near unanimous support from both parties, passed bills related to Medicaid expansion; however, neither bill advanced due to disagreements between the two chambers on unrelated provisions.

Financial incentives from the federal government helped to gain new support from Republican legislators. Under the ACA, states receive a 90% federal matching rate (FMAP) for adults covered through the ACA expansion, a higher share than it does for traditional Medicaid enrollees. In 2021, the temporary fiscal incentive under the American Rescue Plan Act (ARPA) reignited discussion around Medicaid expansion in a  few  non-expansion states, including North Carolina. Under ARPA, states that newly adopt expansion are eligible for an additional 5 percentage point increase in the state’s traditional FMAP for two years, resulting in a temporary net fiscal benefit for these states. New support for adopting Medicaid expansion among Republican lawmakers was attributed to the fiscal incentives among other reasons for their change in opinion. At the time of passage of the state budget, the Joint Conference Committee estimated the ARPA incentive would bring a fiscal benefit of about $1.5 billion over two years and appropriated many of these funds to health-related initiatives. Additionally, the legislation adopting Medicaid expansion authorized the Healthcare Access and Stabilization Program (HASP), a directed payment program funded through increased hospital assessments that provides eligible hospitals with supplemental payments. According to the state, Medicaid expansion and HASP will allow the state to receive more than $8 billion each year from the federal government.

The substantial body of research pointing to largely positive effects of expansion may have also been a consideration in adopting expansion. Although it appears financial incentives were a primary motivator for state legislators formerly opposed to Medicaid, the Joint Legislative Committee on Access to Healthcare and Medicaid Expansion was presented with findings on the impact of Medicaid expansion. KFF reports published in 2020 and 2021 reviewed more than 600 studies and concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers. More recent studies generally find positive effects related to more specific outcomes such as improved access to care, treatment and outcomes for cancer, chronic conditions, sexual and reproductive health, and behavioral health. Studies also point to evidence of reduced racial disparities in coverage and access, reduced mortality, and improvements in economic impacts for providers (particularly rural hospitals) and economic stability for individuals.

What to watch moving forward?

How will expansion intersect with other ongoing and planned reforms in North Carolina? In addition to Medicaid expansion, North Carolina is also implementing major delivery system reforms and activities to address social determinants of health and reduce disparities. Beginning July 1, 2021, North Carolina implemented its first Medicaid managed care organization (MCO) program with the launch of MCO “Standard Plans,” offering integrated physical and behavioral health services statewide, with mandatory enrollment for most population groups; most expansion enrollees will receive coverage through Standard Plans. The state also recently submitted an 1115 waiver extension request that includes requests to cover a set of pre-release services for justice-involved individuals and to expand the Healthy Opportunities Pilots program that covers non-medical services that address specific social needs linked to health outcomes. The implementation of Medicaid expansion extends Medicaid coverage to more North Carolinians who could be eligible for these services.

How will Medicaid expansion intersect with unwinding of the continuous enrollment provision and what will be the effect on the uninsured? All states are currently conducting redeterminations for all Medicaid enrollees due to the unwinding of pandemic-related eligibility protections. During unwinding, states will disenroll those who are no longer eligible or who may remain eligible but are unable to complete the renewal process. North Carolina began Medicaid disenrollments in July 2023, and as of November 2023, 181,375 enrollees were disenrolled. Without expansion, adults disenrolled from Medicaid with incomes below poverty may have fallen into the coverage gap but now could be eligible for expansion coverage. Managing the unwinding in conjunction with implementing expansion may require additional eligibility and enrollment staff to help manage the volume of renewals and new applicants simultaneously. While many states may experience increases in the number of people uninsured as people are disenrolled from Medicaid coverage, North Carolina could see reductions in the uninsured as more adults become eligible and enroll in expansion coverage.

What does this mean for other non-expansion states? Looking ahead expansion could be a federal election issue as the Biden administration continues to encourage states to adopt expansion and has also proposed measures to cover people in states that do not expand. At the same time, Republican presidential candidates, including former President Trump and Governor Ron DeSantis, have called for renewed efforts to repeal and replace the ACA. In addition, Governor DeSantis of Florida and former Governor of South Carolina Nikki Haley have opposed Medicaid expansion in their states. While a number of states have been able to adopt expansion through a ballot measure, that option is not available to most other non-expansion states. At the state level, Medicaid expansion was a topic in the recent Mississippi gubernatorial race, but Governor Tate Reeves was re-elected in 2023, taking expansion off the table. Expansion is unlikely to be a major issue in upcoming statewide gubernatorial elections, as none of the remaining non-expansion states have a gubernatorial election in 2024; however, there could be changes in the make-up of state legislatures. Some states to watch include Kansas and Wisconsin, where Democratic governors have continued to support expansion. Kansas’ governor recently re-initiated discussion of Medicaid expansion, but it is unclear if the state legislature will take-up the proposal.