There have been increased attention and calls to address racism in the U.S. in recent years, particularly in the wake of the initial wave of the COVID-19 pandemic and the growth in recognition of the harms caused by systemic racism following the police killings of George Floyd and Breonna Taylor. As a result of historic and ongoing policies often rooted in discriminatory practices, there are stark differences in access to resources, opportunities, and power by race and ethnicity in the U.S., including access to safe housing and neighborhoods, economic and educational opportunities, and health care. Racism and discrimination at multiple levels, intentional or not, result in differences in experiences across many aspects of everyday life as well as in health care settings, which can negatively impact individuals’ health and well-being. Moreover, reflecting the intersectional nature of people’s identities, some individuals experience the combined impacts of racism and discrimination based on other factors such as gender or sexual orientation.

KFF’s 2023 Racism, Discrimination, and Health Survey is a major effort to document the extent and implications of racism and discrimination, particularly with respect to people’s interactions with the health care system. This large, nationally representative survey based on responses from over 6,000 adults provides new data on individuals’ experiences with racism and discrimination and the impacts of these experiences, both broadly and within racial and ethnic groups. It documents racial and ethnic differences in social and economic circumstances, interactions with the police, experiences with unfair treatment in daily life and while seeking health care, and the impacts of such experiences on health and well-being. Moreover, it examines how these inequities and experiences vary within racial and ethnic groups by factors such as income, gender, skin tone, age and LGBT identity where data allow. Future publications will delve deeper into results for specific populations and additional topics. This survey is part of a broader body of work that builds on KFF’s commitment to amplifying the voices of marginalized populations, including the recently released 2023 KFF/LA Times Survey of Immigrants, which provides insight into experiences of immigrants by different factors including immigration status. Having comprehensive and nuanced data to understand individuals’ experiences may inform and direct efforts to address disparities and advance equity.

This report is broadly divided into three sections. The first examines how social and economic circumstances and feelings of safety for Hispanic, Black, Asian, and American Indian and Alaska Native (AIAN) people in the U.S. differ from White individuals in ways that reflect underlying structural inequities. The second section examines experiences with interpersonal racism and discrimination in daily activities and impacts of these experiences on well-being and stress. The third section delves deeper into experiences with racism and discrimination in health care settings.

Acknowledgements:

KFF would like to thank the following individuals and organizations for their invaluable inputs, insights, and suggestions throughout the planning and dissemination of this survey project:

Mayra Alvarez, MHA, The Children’s PartnershipUché Blackstock, MD, Advancing Health EquityKimberly Chang, MD, MPH, Asian Health ServicesJuliet Choi, JD and Mary Smith, JD, Asian and Pacific Islander Health ForumGail Christopher, DN, National Collaborative for Health EquityCarmen Green, MPH, Reproductive Health ImpactDaniel Dawes, JD, Institute of Global Health Equity, Meharry Medical CollegeAdolph P. Falcón, MPP, National Alliance for Hispanic HealthSharlene Kemler, The Loveland FoundationPedro Martinez, MPH, UnidosUSAletha Maybank, MD, MPH, and Fernando De Maio, PhD, American Medical AssociationMeredith Raimondi, National Council of Urban Indian HealthA.C. Locklear, JD, National Indian Health Board

Key Takeaways

Reflecting ongoing residential segregation patterns rooted in contemporary and historic policies, Hispanic, Black, Asian, and AIAN adults feel less safe in their homes and neighborhoods and experience higher rates of police mistreatment compared to White adults. Hispanic, Black, Asian, and American Indian and Alaska Native (AIAN) adults are significantly less likely than White adults to say they feel “very safe” in their neighborhoods and in their homes, and about one in ten in each of these groups say they or a family member was a victim of violence in the past year, about twice the share of White adults who say so. About one in six AIAN adults and one in ten Black and Hispanic adults say they or a family member living with them have been threatened or mistreated by the police in the past year compared with 4% of White adults. Black and Hispanic adults who have self-reported darker skin tones report even higher rates of police mistreatment. Hispanic, Black, and AIAN adults also report disproportionate challenges with finances and employment due to underlying structural inequities, which are reflected in their daily worries and concerns. Among adults overall and across most racial and ethnic groups, having a strong network of local support is associated with increased feelings of safety in their homes and neighborhoods and reduced frequency of worries and concerns about meeting their family’s basic needs and health.

At least half of AIAN, Black, and Hispanic adults and about four in ten Asian adults say they have experienced at least one type of discrimination in daily life at least a few times in the past year, and they are more likely to say these experiences were due to their race or ethnicity compared to their White counterparts. These experiences include receiving poorer service than others at restaurants or stores, people acting as if they are afraid of them, people acting as if they are not smart, being threatened or harassed, or being criticized for speaking a language other than English. Overall, four in ten Black adults and about three in ten Hispanic, Asian, and AIAN adults say they have experienced at least one of these acts of discrimination in the past year and that their race or ethnicity was a reason for these experiences compared with just 6% of White adults.

Highlighting the impacts of racism and discrimination on well-being and health, people who report experiences with discrimination in daily life are more likely than those who rarely or never experience discrimination to report adverse effects from worry or stress as well as regular feelings of loneliness, anxiety and depression. For example, those who experienced discrimination in their everyday lives are at least twice as likely as those who report rarely or never experiencing discrimination to say that in the past 30 days worry or stress has led to sleep problems (65% vs. 35%); poor appetite or overeating (52% vs. 20%) frequent headaches or stomachaches (41% vs. 15%); difficulty controlling their temper (34% vs. 11%); worsening of chronic conditions (19% vs. 9%); or an increase in their alcohol or drug use (19% vs. 6%). Similarly, those who have experienced discrimination are more likely than those who haven’t had these experiences to say they always or often felt anxious, lonely, or depressed in the past year. These patterns are similar across racial and ethnic groups and persist even when controlling for other factors like age, income, gender, and LGBT identity.

Black and AIAN adults report facing particularly high rates of discrimination, and among Black adults, those with self-reported darker skin tones are more likely to report discrimination experiences than those with lighter skin tones. AIAN and Black adults are the most likely to report an experience with discrimination in daily life asked about in the survey, with over half of both groups saying they experienced at least one of these types of discrimination at least a few times a year and about three in ten reporting experiencing two or more of these types of discrimination at least a few times a year. Among Black adults, those who say their skin color is “very dark,” “dark,” (62%) or “medium” (55%) are more likely to report an experience with discrimination compared with 42% of Black adults who say their skin color is “very light” or “light.”

Specific discrimination experiences also vary by gender, with Black men being the most likely to say people act as if they are afraid of them and Hispanic women most likely to say they are treated as if they are not smart. About a quarter (27%) of Black men say people acted afraid of them in the past year, as do 17% of Hispanic men and 17% of Black women, compared with about one in ten among Hispanic women and White and Asian adults of either gender. Conversely, the share who say they were treated as if they are not smart is higher among Hispanic women (37%) than Hispanic men (27%). Hispanic women are also more likely than Hispanic men to say they received poorer service than others in stores or restaurants at least a few times in the past year (29% vs. 21%). Discrimination experiences also vary by LGBT identity and age. About two-thirds (65%) of LGBT adults say they experienced at least one form of discrimination measured in the survey in the past year compared to four in ten (40%) non-LGBT adults, although there are no significant differences by race and ethnicity among LGBT adults. Similarly, over half (54%) of adults ages 18-49 report these experiences compared to three in ten (29%) of those ages 50 and over.

Experiences with unfair treatment extend into health care, with Black, Hispanic, AIAN, and Asian adults reporting higher levels of unfair treatment when seeking health care than their White counterparts, and Black women report even higher rates of unfair treatment. About one in five Black adults (18%) and about one in ten Hispanic (11%), Asian (10%) and AIAN (12%) adults say they have been treated unfairly or with disrespect by a health care provider in the past three years because of their race or ethnic background compared with 3% of White adults. Among Black adults, women are more likely than men to say they were treated unfairly by a health care provider because of their racial or ethnic background (21% vs. 13%).

Reflecting experiences with unfair treatment, large shares of Black, AIAN, Hispanic, and Asian adults say they prepare for possible insults or feel they must be very careful about their appearance to be treated fairly during health care visits. Six in ten (60%) Black adults, about half of AIAN (52%) and Hispanic (51%) adults, and four in ten (42%) 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 compared with one in three (33%) White adults.

Having providers with a shared background matters, as Black, Hispanic, and Asian adults who have more health care visits with providers who share their racial and ethnic background report more frequent positive and respectful interactions. Reflecting limited racial and ethnic diversity of the health care workforce, most Hispanic, Black, Asian, and AIAN adults say that fewer than half of their health care visits in the past three years were with a provider who shared their racial or ethnic background. However, the survey shows how provider racial and ethnic concordance can make a difference in patient interactions. For example, Black adults who had at least half of recent visits with a provider who shares their background are more likely than those who have fewer of these visits to say that their doctor explained things in a way they could understand (90% vs. 85%), involved them in decision-making about their care (84% vs. 73%), understood and respected their cultural values or beliefs (84% vs. 76%), or asked them about social and economic factors (39% vs. 24%) during recent visits.

A third of adults overall report at least one of several negative experiences with a health care provider in the past three years, and many Black, Hispanic, Asian, and AIAN adults say they were treated this way because of their race or ethnicity. These negative experiences include a provider assuming something about them without asking, suggesting they were personally to blame for a health problem, ignoring a direct request or question, or refusing to prescribe pain medication they thought they needed. About a quarter (24%) of Black adults and one in five (19%) AIAN adults say they experienced at least one of these negative experiences and that their race or ethnicity was a reason why they were treated this way, as do 15% of Hispanic and 11% of Asian adults, compared with just 4% of White adults.  Notably, 22% of Black adults who were pregnant or gave birth in the past ten years say they were refused pain medication they thought they needed, roughly twice the share of White adults with a pregnancy or birth experience (10%).

Negative experiences with health care providers as well as language access challenges have consequences for health and health care use. Among adults who used health care in the past three years, one in four (25%) say they had a negative experience (including being treated unfairly or with disrespect, a negative provider interaction, or difficulty with language access), and it led to worse health, being less likely to seek care, and/or switching providers. AIAN and Black adults are more likely than White adults to say they had a negative experience and it contributed to at least one of these consequences.

Implications

The survey reveals that, in wake of the initial COVID-19 pandemic and amid ongoing economic challenges and political division within the U.S., people’s experiences in their everyday lives and in health care settings often vary starkly by race and ethnicity, highlighting the ongoing impacts of racism and discrimination within the health care system and more broadly. The survey shows that many challenges are shared across all adults, including White adults, but that Hispanic, Black, Asian, and AIAN adults face disproportionate challenges and higher rates of unfair treatment due to their race and ethnicity, which have implications for health and well-being. The survey data identify areas for increased attention, resources, and initiatives to address these challenges and disparities, such as mechanisms to improve social and economic circumstances and provide safer communities as well as to address ongoing bias and discrimination, particularly in health care. The survey results also highlight factors that mitigate some of these challenges, including having strong local support networks and more health care visits with providers who have a shared racial and ethnic background. They also illustrate opportunities to increase respectful and positive provider interactions that can support high-quality and culturally competent care. Addressing the challenges identified in the survey is important not only from an equity standpoint but also for improving the nation’s overall health and economic prosperity.

Section 1: Racial and Ethnic Differences in Social and Economic Factors, Safety, and Police Interactions

Historic and contemporary policies contribute to ongoing structural inequities in access to opportunities and resources, shaping where people live, their education and employment, and other factors that influence their daily lives, experiences, and interactions with systems and institutions. For example, historic housing policies, including discriminatory practices such as redlining, have ongoing impacts today, including residential segregation of Black people into urban areas with fewer resources and educational opportunities and higher rates of poverty, violence and crime. The survey shows racial and ethnic differences in finances and employment, feelings of safety and exposure to violence, and interactions with the police that reflect these types of underlying inequities.

Finances and Employment

Black, AIAN, Hispanic, and Asian adults face increased challenges across an array of social and economic factors relative to White adults, which reflect underlying structural inequities, including access to employment and educational opportunities. About three in ten AIAN (29%) and Black (28%) adults, one quarter (24%) of Hispanic adults, and one in five (20%) Asian adults say they or a family member experienced problems getting or keeping a job in the past year compared with 15% of White adults (Figure 1). Just under half of AIAN (48%) and Black (45%) adults say they or a family member had a problem paying for food, housing, transportation, or other necessities in the past year, nearly twice the share of White adults (27%) who report these issues. Similarly, about one in five Black (22%) and AIAN (22%) adults and one in seven Hispanic adults (15%) say they have difficulty affording their bills each month, larger than the share of White adults who say this (11%). In contrast, paying for health care is a common challenge across racial and ethnic groups. At least one in five adults across racial and ethnic groups say they or a family member living with them had a problem paying for health care in the past 12 months. Hispanic adults are more likely than White adults to report problems affording health care in the past year (27% vs. 23%), reflecting that they have a higher rate of being uninsured.

Differences in finances and employment may also reflect bias and discrimination, with Black and AIAN adults more likely than White adults to report unfair treatment in the workplace and in housing. About four in ten Black (42%) and AIAN (42%) adults say they have ever been paid less than other people doing the same job compared with a third (33%) of White adults (Figure 2). Black adults are also more likely than White adults to say they have ever been fired, denied a job, or denied a promotion for unfair reasons (27% vs. 20%), and Black and AIAN adults are more likely than White adults to say they have ever been evicted or denied housing (14% and 13% vs. 5%).

Safety, Exposure to Violence, and Police Interactions

Reflecting ongoing residential segregation patterns rooted in historic and contemporary policies, Black, Hispanic, Asian, and AIAN adults say they feel less safe in their homes and neighborhoods compared to White adults. Large majorities of adults across racial and ethnic groups report feeling at least somewhat safe in their neighborhoods. However, Black, Hispanic, Asian, and AIAN adults are less likely than White adults to say they feel “very safe.” Roughly half of each group say they feel very safe in their neighborhood compared to about two-thirds of White adults (Figure 3). Similarly, vast majorities of adults across racial and ethnic groups say they feel at least somewhat safe in their homes, but the shares of Black, Hispanic, and AIAN adults (61% each) and Asian adults (55%) who report feeling very safe in their home are lower than the share of White adults who say this (73%).

Having a strong network of local support is associated with increased feelings of safety. Specifically, adults who say they have “a lot” or a “fair amount” of family members or friends living near them who they can ask for help or support are more likely to say they feel “very safe” in their home or neighborhood than those who have “just a few” or no family members or friends nearby that they can ask for support. For example, among Asian adults, about six in ten (62%) of those with “a lot” or a “fair amount” of family and friends nearby say they feel very safe in their home compared with about half (47%) of those with “just a few” or no close by family and friends available for support (Figure 4). Among adults overall and across most racial and ethnic groups, this relationship between having a local support network and feelings of safety remains significant even after controlling for other demographic characteristics including education, income, gender, LGBT identity, and age.¹ 

While few adults overall say they or a family member have been a victim of violence, the shares are higher among Hispanic, AIAN, Black, and Asian adults as well as those living in urban areas. About one in ten Hispanic (12%), AIAN (11%), Black (9%), and Asian adults (9%) say they or a family member in their household was a victim of an act of violence such as a robbery, carjacking, or shooting in the past year, about twice the share of White adults (5%) who report the same (Figure 5). Among all adults, those living in urban areas are more likely than those who live in suburban and rural communities to say they or a family member have been a victim of violence in the past year, with about one in ten Hispanic (13%), Black (12%), and White (9%) adults living in urban areas reporting this. Among those living in rural communities, however, Black adults are significantly more likely than White adults to say they or someone in their family have been a victim of violence in the past year (9% vs. 2%).

Beyond differences in safety and experiences with violence, Black, AIAN, and Hispanic adults are more likely than White adults to say they or a family member experienced recent mistreatment by the police, particularly Black and Hispanic adults with self-reported darker skin tones. About one in six AIAN adults (17%) and about one in ten Black (11%) and Hispanic (8%) adults say they or a family member living with them have been threatened or mistreated by the police in the past year compared with 4% of White adults (Figure 6). For Black and Hispanic adults, the shares reporting recent police mistreatment are larger among those with self-described darker skin tones compared to those with lighter skin tones. For example, 12% of Black adults with self-described “very dark,” “dark,” or “medium” skin tones say they or a family member living with them have been threatened or mistreated by police compared to 7% of those with lighter skin tones. Similar differences occur among Hispanic adults between those with darker vs. lighter skin tones (10% vs. 5%).

Daily Worries and Concerns

People’s frequent daily worries and concerns reflect these racial and ethnic differences in finances and employment, safety, and police interactions. About one in five AIAN (23%), Black (21%), and Hispanic (18%) adults say that in the past 30 days they experienced worry or stress related to providing for their family’s basic needs either “every day” or “almost every day” compared to fewer White adults (13%) (Figure 7). Similarly, larger shares of AIAN, Black, and Hispanic adults compared to White adults say they experienced daily or near-daily worry about experiences with racism and discrimination and the possibility of someone in their family being a victim of gun or police violence. AIAN, Black, and Hispanic adults are also more likely to say they frequently experienced worry or stress related to their health in the past 30 days compared to their White counterparts. Having a strong local support network, as measured by having at least a “fair amount” of friends and family living nearby who you can ask for help or support, mitigates the frequency of worries and concerns about providing for basic needs and health among adults overall and across most racial and ethnic groups.² 

Section 2: Experiences with Discrimination in Daily Life and Their Impacts on Wellbeing and Stress

Black, AIAN, Hispanic, and Asian adults are more likely to report certain experiences with discrimination in daily life compared with their White counterparts, with the greatest frequency reported among Black and AIAN adults. For example, about one-third of Black adults (35%) and about a quarter of AIAN (28%), Hispanic (25%), and Asian adults (25%) say that they received poorer service than other people at restaurants or stores at least a few times in the past year, all higher than the share of White adults who say the same (16%) (Figure 8). Similarly, about four in ten AIAN adults (42%) and one-third (33%) of both Black and Hispanic adults say that people have acted as if they think they are not smart at least a few times in the past year, higher than the one-quarter (26%) of White adults who say so. In addition, Asian (17%) and Black adults (16%) are somewhat more likely than White adults (13%) to say they were threatened or harassed at least a few times in the past year. Further, about one in five Black (21%) and AIAN adults (19%) as well as 13% of Hispanic adults say people acted as if they were afraid of them at least a few times in the past year, compared to 9% of White adults. Among those who completed the survey in a language other than English, one-quarter (24%) say they were criticized for speaking another language in public in the past year, including 28% of Hispanic adults who responded in Spanish. Cumulatively, at least half of AIAN (58%), Black (54%), and Hispanic adults (50%) say they have experienced one of these forms of discrimination at least a few times in the past year, as do four in ten Asian adults (42%). About four in ten (38%) White adults also say they have experienced at least one of these types of discrimination in the past year.³ 

Black, AIAN, Hispanic, and Asian adults are more likely than White adults to report experiencing more than one of these types of discrimination. Three in ten Black (31%) and AIAN adults (28%) and about one in four Hispanic (26%) and Asian adults (25%) say they experienced at least two of these types of discrimination at least a few times in the past year, all higher than the share of White adults who say so (18%) (Figure 9).

When discrimination in daily life occurs, Black, Hispanic, AIAN, and Asian adults are far more likely than White adults to say their race or ethnicity was a factor in these experiences. Among those who say they experienced at least one form of discrimination measured in the survey, most Black, Hispanic, AIAN, and Asian adults say their race or ethnicity was a major or minor reason they were treated this way, compared to a much smaller share of White adults. Overall, four in ten Black adults (40%) and about three in ten Hispanic (30%), AIAN (30%), and Asian adults (28%) say they experienced at least one of these acts of discrimination in the past year and say their race or ethnicity was at least a minor reason for these experiences. By contrast, only 6% of White adults report this (Figure 10).

Across racial and ethnic groups, reports of experiences with discrimination in daily life are particularly high among younger adults and LGBT adults. There is a strong relationship between age and reports of discrimination in daily life, with a majority of adults ages 18-29 (62%) and about half of 30-49 year-olds (49%) reporting such experiences compared to smaller shares of those ages 50-64 (36%) and 65 and over (22%) (Figure 11). This pattern is consistent across racial and ethnic groups. Similarly, about two-thirds (65%) of LGBT adults say they experienced at least one form of discrimination measured in the survey at least a few times in the past year compared to four in ten non-LGBT adults (40%). Among LGBT adults, there are no differences by race and ethnicity, with about two-thirds of Hispanic (69%), Black (64%), and White (64%) LGBT adults reporting discrimination experiences in the past year.

A somewhat larger share of women compared to men report at least one of these discrimination experiences, but this overall pattern masks some differences in individual measures. For example, a larger share of women compared to men say they were treated as if they were not smart in the past year (33% vs. 23%), while men are more likely than women to say people acted as if they were afraid of them (14% vs. 9%).

The combination of race, ethnicity, and gender also highlights disproportionate discrimination for certain groups. For example, 27% of Black men say people acted afraid of them in the past year, as do 17% of Hispanic men and 17% of Black women. For Hispanic women and White and Asian adults of either gender, these shares are about one in ten. Conversely, the share who say they were treated as if they are not smart is higher among Hispanic women (37%) than Hispanic men (27%). Hispanic women are also more likely than Hispanic men to say they received poorer services than others in stores or restaurants at least a few times in the past year (29% vs. 21%) (Figure 12).

Black adults who self-describe as having darker skin color report more experiences of discrimination in their everyday lives compared to those with lighter skin color. Most Black adults who say their skin color is “very dark” or “dark” (62%) or “medium” (55%) report at least one of these experiences of discrimination, compared with 42% of Black adults who say their skin color is “very light” or “light.” For example, four in ten Black adults who say their skin color is “very dark” or “dark” (42%) say they have received poorer service at restaurants or stores in the past year, compared with about a quarter of those who say their skin color is “very light” or “light” (27%). Black adults with self-reported darker skin color are also more likely to say people acted as if they were afraid of them in the past year compared with those with lighter skin color (25% vs. 18%) (Figure 13).

Among Black adults, those with higher educational attainment report more experiences with discrimination compared to their counterparts with lower educational attainment. Black adults with a four-year college degree are more likely to report experiences of discrimination in their everyday lives compared to those without college education (59% vs. 52% respectively) (Figure 14). Specifically, about four in ten Black adults with a college degree (42%) say they received poorer service at restaurants or stores at least a few times in the past year compared with one-third of Black adults without a college degree (33%). Black adults with a college degree are also more likely to report people acting as if they are afraid of them compared to those without a four-year degree (28% vs. 19%). These findings are consistent with previous research, and may reflect increased exposure to perceived discrimination among those with higher incomes and education levels as well as having greater awareness of racism and therefore greater ability to identify it in different aspects of life.

Relationship Between Discrimination Experiences and Well-being

Racism is an underlying driver of health disparities and repeated and ongoing exposure to perceived experiences of racism and discrimination can increase risks for poor health outcomes. Research has shown that the exposure to racism and discrimination can lead to negative mental health outcomes and certain negative impacts on physical health, including depression, anxiety, and hypertension. Studies also show that perceived discrimination can negatively impact healthy behaviors by increasing smoking and alcohol use and lowering adherence to medical guidance and preventative screenings.

Among all U.S. adults and across racial and ethnic groups, those who report experiences with discrimination in daily life are more likely than others to report adverse effects from worry or stress such as appetite and sleep issues, increased substance use, and worsening of chronic health conditions. Adults who report experiences with at least one type of discrimination in daily life as measured in the survey are more likely than adults who “rarely” or “never” experienced such discrimination to report certain adverse effects of worry or stress. For example, those who experienced discrimination in their everyday lives are more likely than others to say that in the past 30 days worry or stress has led to sleep problems (65% vs. 35%); poor appetite or overeating (52% vs. 20%) frequent headaches or stomachaches (41% vs. 15%); difficulty controlling their temper (34% vs. 11%); worsening of chronic conditions (19% vs. 9%); or an increase in their alcohol or drug use (19% vs. 6%) (Figure 15). Overall, eight in ten (79%) adults who experienced discrimination in the past year say they have had at least one of these adverse effects of worry and stress, compared to about half (47%) of adults who say they rarely or never had these experiences in the past year. These patterns are similar across racial and ethnic groups. While other underlying factors beyond discrimination may contribute to these differences, the relationship between adverse effects of stress and experiences with discrimination remains significant even after controlling for other demographic characteristics including education, income, gender, LGBT identity, and age.⁴ 

Adults who report discrimination experiences in daily life are more likely than those who say they rarely or never experience discrimination to report always or often feeling lonely, depressed, or anxious in the past 12 months. Among those with discrimination experiences, four in ten (40%) say they “always” or “often” felt anxious in the past year, compared to 14% of adults who rarely or never experience such discrimination. Those with discrimination experiences in their daily life are more than three times as likely as others to say they always or often felt lonely (26% vs. 7%) or depressed (25% vs. 7%) in the past year (Figure 16). These patterns are similar across racial and ethnic groups and persist even after controlling for other demographic characteristics including education, income, gender and age.⁵ 

Section 3: Experiences in Health Care Settings

Reflecting underlying structural inequities in the U.S., there are ongoing racial and ethnic disparities in health and health care. AIAN, Hispanic, and Black people have higher uninsured rates compared to their White counterparts and face other increased barriers to accessing care. Among adults in the survey, Hispanic (20%), AIAN (14%), and Black (10%) adults are more likely to report being uninsured compared to White (6%) adults. However, beyond differences in the ability to access care, the survey highlights differences in experiences within the health care system, including interactions with providers, experiences with unfair treatment, and the consequences of these experiences.

Provider Interactions

Among those who used health care within the past three years, most adults across racial and ethnic groups report having positive and respectful interactions with their health care providers most of the time. Health care that is respectful and responsive to individual preferences, needs, and values is an important component of health care quality and equitable health care. Among those who used health care in the past three years, large shares say that their health care providers explained things in a way they could understand (89%), respected their cultural values and beliefs (84%), involved them in decision-making about their care (81%), and spent enough time with them (76%) most of the time or every time during visits. Across racial and ethnic groups, at least two-thirds say their provider did each of these things at least most of the time.

However, Hispanic, Black, Asian, and AIAN adults report having these positive and respectful interactions with health care providers less often than White adults. For example, AIAN (18%), Asian (18%), and Hispanic (16%) adults are about twice as likely as White adults (8%) to say their health care providers explained things in a way they could understand just some of the time, rarely, or never in the past three years (Figure 17). Similarly, about one in four AIAN adults (24%) and about one in five Black (21%), Asian (21%) and Hispanic (19%) adults say their health care providers understood and respected their cultural beliefs just some of the time, rarely, or never compared with about one in ten White adults (12%). These groups also are more likely than their White counterparts to say their providers did not frequently involve them in decision-making about their care during their visits in the past three years. Many of these racial and ethnic differences persist among adults with higher incomes and those with health coverage. Among Hispanic adults there also are some differences by English proficiency. For example, Hispanic adults who have limited English proficiency are about twice as likely as those who are English proficient to say they their providers rarely or never involved them in decision-making about their care in the past three years (16% vs. 9%).

Few adults across racial and ethnic groups say a health care provider frequently asked them about their work, housing situation, or access to food or transportation in the last three years. While health coverage and access to health care shape health, social and economic factors, such as employment, housing, food access, and transportation also play a major role. Research indicates that screening for social and economic risks can positively impact health, and there are growing efforts among some providers focused on serving low-income populations to screen for social risks and needs. However, just over one in four (27%) adults who used health care in the last three years say a health care provider asked about their work, housing situation, or access to food or transportation at least most of the time during visits (Figure 18). Overall, and among Hispanic and Asian adults, lower income adults are more likely than higher income adults to say a provider asked about these factors most of the time or every time, but majorities of lower income adults still say this happens just some of the time, rarely, or never.

Reflecting limited racial and ethnic diversity of the health care workforce, Black, Hispanic, AIAN, and Asian adults are less likely than White adults to say most of their recent health care visits were with a provider who shares their racial and ethnic background. At least half of Black (62%), Hispanic (56%), AIAN (56%) and Asian (53%) adults who used health care in the past three years say that fewer than half of their visits were with a provider who shared their racial and ethnic background (Figure 19). In contrast, about three-quarters (73%) of White adults say that half or more of their visits were with a provider who shares their racial and ethnic background.

Black, Hispanic and Asian adults who have at least half of their visits with providers who share their racial or ethnic background report having more frequent positive and respectful interactions with providers. For example, among those who used health care in the past three years, Black adults who had at least half of recent visits with a provider who shares their background are more likely than those who have fewer of these visits to say that their doctor explained things in a way they could understand (90% vs. 85%), involved them in decision making about their care (84% vs. 73%), understood or respected their cultural values or beliefs (84% vs. 76%), or asked them about social and economic factors (39% vs. 24%) at least most the time (Figure 20). Patterns are similar for Hispanic adults. Asian adults who had half or more visits with a provider who shared their racial or ethnic background are more likely than those who had fewer such visits to say their provider understood and respected their cultural values and beliefs every time or most of the time.

Despite these differences, few Black, Hispanic, Asian, and AIAN adults say they think they either would or do receive better care from health care providers who share their racial and ethnic background. About a quarter of Black (27%), Hispanic (26%), and Asian adults (24%) and about one in five AIAN adults (19%) say they think they would receive better care from doctors who share their racial or ethnic background, while majorities in each of these groups say they don’t think the race or ethnicity of their provider makes much difference in the quality of care they receive. Other research has shown an association between patients and providers having shared racial and ethnic backgrounds and improved communication but mixed impacts of this patient-provider concordance on patient experiences and health outcomes. However, other recent research suggests racial concordance may contribute to improved health care use and health outcomes including lower emergency department use, reductions in racial disparities in mortality for Black infants, and increased visits for preventative care and treatment.

Experiences with Unfair Treatment by Health Care Providers

About one in five (18%) Black adults and roughly one in ten AIAN (12%), Hispanic (11%), and Asian (10%) adults who received health care in the past three years report being treated unfairly or with disrespect by a health care provider because of their racial or ethnic background. These shares are higher than the 3% of White adults who report this. Among Black adults, women are more likely than men to say they were treated unfairly by a health care provider because of their racial or ethnic background (21% vs. 13%). AIAN (26%) and Black (18%) adults also are more likely than White adults (13%) to say they have been treated unfairly or with disrespect by a health care provider in the past three years due to some other factor, such as their gender, health insurance status, or ability to pay for care (Figure 21). Overall, roughly three in ten (29%) AIAN adults and one in four (24%) Black adults say they were treated unfairly or with disrespect by a health care provider in the past three years for any reason compared with 14% of White adults. Additionally, LGBT adults are about twice as likely as non-LGBT adults to say they experienced unfair treatment by health care provider for any reason in the past three years (33% vs. 15%). Among LGBT adults, similar shares of Black (33%), White (33%), and Hispanic adults (26%) report these experiences.

Reports of unfair treatment by health care providers due to race and ethnicity persist among Black, Hispanic, and Asian adults with higher incomes, who have health coverage, or who have a usual source of care. Overall and among Hispanic adults, those with lower incomes are more likely than those with higher incomes to report unfair or disrespectful treatment by a provider in the past three years. However, even among those with higher incomes (annual household incomes of $90,000 or more), 15% of Black adults report being treated unfairly or with disrespect by a health care provider because of their race or ethnic background, as do higher shares of Asian (8%) and Hispanic (5%) adults compared with White adults (1%) (Figure 22). Among adults with health coverage, 18% of Black adults and one in ten Asian (11%) and Hispanic (10%) adults say they have been treated unfairly by a health care provider in the past three years because of their race or ethnicity compared with 3% of White adults. Similarly, among adults with a usual source of care, one in five Black adults (18%) and about one in ten Hispanic (9%), and Asian (9%) adults report being treated unfairly or with disrespect by a health care provider due to their race or ethnic background compared with just 3% of White adults.

Reflecting these experiences with unfair treatment, large shares of Black, AIAN, Hispanic and Asian adults say that they prepare for possible insults from a provider or staff or feel they need to be very careful about their appearance to be treated fairly during health care visits. Vigilant behaviors, such as preparing for insults or considering one’s appearance, are sometimes adopted by people who experience discrimination as a means of protection from the threat of possible discrimination and to reduce exposure. Research has shown that heightened vigilance is associated with poor physical and mental health outcomes, including hypertension, sleep difficulties, and depression. Over half (55%) of Black adults, about half of AIAN (49%) and Hispanic (47%) adults, and about four in ten (39%) Asian adults say they feel they must be very careful about their appearance at least some of the time to be treated fairly when receiving health care (Figure 23), including one in five (21%) Black adults who say they feel they have to be careful “every time.” Each of these groups is more likely than White adults to report being vigilant about their appearance during health care visits at least some of the time, although notably about three in ten (29%) White adults say they take these actions. About three in ten (29%) Black adults and roughly a quarter of AIAN (26%) and Hispanic (23%) adults say they try to prepare for possible insults during health care visits, all higher than the share of White adults who say this (16%). About one in five Asian adults (19%) also report preparing for insults. Together, six in ten (60%) Black adults, about half of AIAN (52%) and Hispanic (51%) adults, and about four in ten (42%) Asian adults say they engage in at least one of these practices at least some of the time during health care visits compared with one in three (33%) White adults. These shares are also particularly high among LGBT adults across racial and ethnic groups, with at least six in ten Black (63%), Hispanic (61%), and White (60%), LGBT adults saying they take either of these steps.

Among higher income adults and those with health coverage, Black, Hispanic, and Asian adults remain more likely than White adults to say they prepare for insults during health care visits or feel they need to be very careful about their appearance to be treated fairly at least some of the time. While higher income adults generally are less likely than those with lower incomes to say they take these steps, among those with higher incomes ($90,000 or more annually), about half of Black adults (51%) and about four in ten Hispanic (41%) and Asian (38%) adults say they take either of these steps at least some of the time during health care visits, higher than the share of White adults (22%) who say this. Similarly, among adults with coverage, Black (59%), Hispanic (51%), and Asian (42%) adults are more likely than their White (34%) counterparts to say they take either of these steps at least some of the time, including 47% of insured Black adults who say they feel they have to be very careful about their appearance (Figure 24).

Negative Experiences When Receiving Health Care

A third of adults who received health care in the past three years report at least one of several negative experiences with a health care provider, including a provider assuming something about them without asking, suggesting they were personally to blame for a health problem, ignoring a direct request or question, or refusing to prescribe pain medication they thought they needed. While many of these negative experiences are shared across racial and ethnic groups, including White adults, AIAN adults are more likely than their White counterparts to say a provider assumed something without asking (29% vs. 19%), ignored a direct request or question (29% vs. 15%), and refused to prescribe pain medication they thought they needed (19% vs. 9%) (Figure 25). In addition, Black adults are more likely than White adults to say a provider ignored a direct request or question (19% vs. 15%) or refused them pain medication they thought they needed (15% vs. 9%). These differences persist among Black adults with health coverage but are not significant after controlling for income.

AIAN, Black, Hispanic, and Asian adults are more likely than White adults to say they had at least one of these negative experiences with a health care provider due to their race and ethnicity. Among adults who received health care in the past three years, about a quarter (24%) of Black adults and one in five (19%) AIAN adults say they experienced at least one of these negative experiences and that their race or ethnicity was a major or minor reason why they were treated this way, as do 15% of Hispanic and 11% of Asian adults. Just 4% of White adults who received care report a negative experience due to their race or ethnicity.

White and Asian women are more likely than their male counterparts to report at least one of these negative experiences with health care providers, but there are no significant differences between Hispanic and Black women and men. Among adults overall, the largest differences by gender include women being more likely than men to say a provider assumed something without asking and a provider ignoring a direct request or question (Figure 26). Additionally, 22% of Black adults who were pregnant or gave birth in the past ten years say they were refused pain medication they thought they needed, roughly twice the share of White adults with a pregnancy or birth experience (10%).

Among adults with limited English proficiency, about half (48%) say that difficulty speaking or reading English made it difficult to complete at least one of several activities related to using health care in the past three years. These activities include filling out forms at a doctor’s office (34%), communicating with staff at a doctor’s office (33%), understanding instructions from a health care provider (30%), filling a prescription or knowing how to use it (27%), or scheduling a medical appointment (25%).

One in four adults who used health care in the past three years report that they had one or more of these negative experiences with a health care provider and/or a language access challenge and that it resulted in worse health, them being less likely to seek care, and/or them switching providers. About four in ten (39%) AIAN adults and three in ten (30%) Black adults say they had a negative experience with one of these consequences compared with about one in four (24%) White adults (Figure 27). The shares of Hispanic and Asian adults reporting a negative experience with at least one of these consequences are similar to that of White adults.

Implications

The survey reveals that, in wake of the initial COVID-19 pandemic and amid ongoing economic challenges and political division within the U.S., people’s experiences in their everyday lives and in health care settings often vary starkly by race and ethnicity, highlighting the ongoing impacts of racism and discrimination within the health care system and more broadly. The survey shows that many challenges are shared across all adults, including White adults, but that Hispanic, Black, Asian, and AIAN adults face disproportionate challenges and higher rates of unfair treatment due to their race and ethnicity, which have implications for health and well-being. The survey data identify areas for increased attention, resources, and initiatives to address these challenges and disparities, such as mechanisms to improve social and economic circumstances and provide safer communities as well as to address ongoing bias and discrimination, particularly in health care. The survey results also highlight factors that mitigate some of these challenges, including having strong local support networks and more health care visits with providers who have a shared racial and ethnic background. They also illustrate opportunities to increase respectful and positive provider interactions that can support high-quality and culturally competent care. Addressing the challenges identified in the survey is important not only from an equity standpoint but also for improving the nation’s overall health and economic prosperity.

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

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

Sampling strategy:

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

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

Incentives:

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

Community and expert input:

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

Translation:

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

Data quality check:

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

Weighting:

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

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

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

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

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

Appendix 1

Racial and ethnic groups included in this report are defined using a two-question format. The initial question asks respondents if they are of Latino or Hispanic origin or descent. The second question asks respondents to select as many racial identity groups as apply from a list that includes eight response options: White, Black or African-American, Asian, American Indian, Alaska Native, Native Hawaiian, Pacific Islander, and “some other race” (with a text box for respondents to provide details). The wording for these questions is similar to the standard two-question measure used by the U.S. Census Bureau, other government organizations, and some survey research organizations. Using the two-question format and “select all that apply” for racial identity allows respondents to self-identify into multiple categories that better reflect their racial and/or ethnic identity or identities.

The table below provides some breakdown on the racial and ethnic identities for the Hispanic, Black, Asian, and American Indian and Alaska Native (AIAN) groups. It includes both the unweighted number of interviews and the weighted proportion within each group, including the share who selected only one race (single race), the share who selected more than one race (multiracial), and the share who selected Hispanic ethnicity within each of these groups. About nine in ten Hispanic adults identify as Hispanic and a single race, and at least eight in ten Black and Asian adults identify as a single race and non-Hispanic. By contrast, most AIAN adults identify as multiracial and about one-third identify as Hispanic.

Appendix 2: Reporting on the Experiences of American Indian and Alaska Native Adults

Sample and Population Represented: The KFF Survey on Racism, Discrimination, and Health was designed to include large samples of adults identifying as Black or African American, Latino or Hispanic, and Asian, with the goal of reporting results specifically for these populations. More details on the sampling strategy are available in the project Methodology.

In addition to these planned larger samples, the sample design also yielded 267 interviews with individuals identifying as American Indian (n=263) and/or Alaska Native (n=6). The American Indian and Alaska Native (AIAN) sample includes individuals who identified AIAN as their only racial identity as well as those who selected AIAN and at least one other race, as well as those who identified as having Hispanic and non-Hispanic ethnicity (see Appendix 1 for more details on how racial and ethnic groups were categorized in this analysis).

Limitations and Data Quality Considerations: Given ongoing concerns about data erasure and invisibility of smaller populations, including Indigenous people, KFF has decided to include results for the AIAN population in this report despite some limitations. The following describes the limitations of the sample, adjustments made to make the sample more representative, and considerations for data interpretation.

Because the survey was not explicitly designed to include a representative sample of AIAN people, the research falls short of some recommended best practices for surveying this population. These include advance outreach to Tribal organizations, face-to-face interviews for some groups, and geographic oversampling of federally recognized Indian reservations and other Tribal lands. The small size of the AIAN sample also does not allow for reporting on more detailed groups (such as within the AIAN population by age, geography, and other demographics).

To increase representativeness of the results, the AIAN sample was weighted to the most current demographic data available for this population: the U.S. Census Bureau’s 2022 American Community Survey (ACS). The weighting parameters include education, age by gender, region, nativity (U.S.-born vs. foreign-born), race and ethnicity, and U.S. citizenship.

Researchers also took other steps to assess the representativeness of the AIAN sample. While Tribal lands were not explicitly included in the sampling strategy, the sample was analyzed to assess whether individuals living on federally recognized Indian reservations and other Tribal lands could have responded to the survey using the Census tracts and zip codes of survey respondents. Overall, 19% of respondents in the AIAN sample live in geographic areas where Tribal lands are located, including 25% of those who identify as AIAN alone. In addition, researchers compared this AIAN sample to other federally available data across a series of benchmarks not included in the weighting such as insurance status, insurance type, income, and the use of English in the household.

Despite these efforts, we suggest using caution when interpreting the results of the AIAN sample in the report. The data included may not be reflective of the entirety of experiences of the AIAN adult population. It may particularly fall short of capturing the experiences of those living on federally recognized Indian reservations and other Tribal lands. In addition, the Census data used for weighting is imperfect and may overrepresent the experiences of multiracial AIAN individuals, which may lead to a similar imbalance in the survey results.

KFF is committed to improving our future efforts and working to more fully represent and reflect the diversity of experiences among Indigenous people in our survey and other work.

1. To examine the relationship between variables of interest throughout the report, a series of logistic regression models were conducted to test whether these relationships hold after controlling for demographics. The demographic variables used across models include educational attainment, income, age, gender, LGBT identity, and region. Race and ethnicity were also included as control variables in the overall model. To test the same relationships within racial and ethnic groups, separate logistic regressions were conducted among Hispanic adults, Black adults, Asian adults, and White adults, controlling for the same demographics listed. ↩︎
2. Based on regression analysis as described above. ↩︎
3. The survey questionnaire was designed by KFF researchers, drawing on previous research. Several items measuring discrimination in everyday life were informed by the Everyday Discrimination Scale. For more information see: https://scholar.harvard.edu/davidrwilliams/node/32397 ↩︎
4. Based on regression analysis as described above. ↩︎
5. Based on regression analysis as described above. ↩︎

Key Takeaways

• With the 2024 presidential election cycle in full swing, voters want to hear the candidates talk about many different issues, and voters identify inflation, including the rising cost of household expenses, as the most important topic for discussion. Notably, the affordability of health care came in a close second with eight in ten voters saying it is “very important” for candidates to discuss on the campaign trail.
• Once a longstanding issue for the Republican Party, former President Trump has recently resurrected the debate around the future of the 2010 Affordable Care Act (ACA). Surveyed prior to this discussion, Democratic voters are more than twice as likely as Republicans voters to say the future of the ACA is a “very important” issue for the candidates to discuss (70% v. 32%). The Democratic Party holds an advantage on which party voters trust to do a better job of handling the ACA with six in ten (59%) voters saying they trust the Democratic Party more, compared to four in ten (39%) who say they trust the Republican Party more. Partisans differ, with nearly all Democratic voters saying they trust the Democratic Party (94%), while three in four (77%) Republican voters say they trust the Republican Party. The Democratic Party holds the advantage among independent voters (61% v. 36%).
• The 2024 election will be the first presidential election since the Dobbs decision. While few voters overall (4%) say abortion is the “most important” issue for 2024 presidential candidates to talk about as they campaign, the Democratic Party holds a strong advantage over the Republican Party on voters’ trust to handle abortion (58% vs. 41%). The Democratic Party hold the advantage on trust on this issue across key voting blocs including women voters overall (61%), women voters ages 18 to 49 (66%), independent women voters (66%), and almost all Democratic women voters (94%).
• While two-thirds of the public now say abortion should be legal in “all” or “most” cases, most voters (57%) say a candidate’s position on abortion is only one of many factors in their vote choice. About a quarter of voters (24%) say they would only vote for a candidate who shares their views on the issue, including larger shares of Democratic voters (33%), including three in ten Democratic women (31%) and one-third of Democratic men (35%) – groups where large majorities say abortions should be legal. Notably, one in four (27%) Republican voters who believe abortion should be illegal in “all” or “most” cases also say they would only vote for a candidate who shares their views on abortion. Among Republican voters who believe abortion should be legal in all or most cases, very few (4%) say they would only vote for a candidate who shares their views on the issue.
• The poll also takes a look at public awareness around two key health policy issues including the unwinding of the Medicaid continuous enrollment provision and the prescription drug provisions included in the 2022 Inflation Reduction Act, revealing that most of the public is unaware of these actions. Medicaid enrollees themselves are among the most likely to say they are aware of the unwinding, but still a majority say they have heard either “nothing” or “only a little” about the unwinding. Among those who are aware, large majorities are worried that this means many adults and children will become uninsured.

Key Issues in the 2024 Election

Less than one year until the 2024 election, there are many issues that voters are eager to hear about from presidential candidates, with two economic issues topping the list: inflation and the affordability of health care. Although inflation is now at a 2-year low, consumers continue to notice high prices. At least eight in ten voters say it is “very important” for the 2024 presidential candidates to talk about inflation (86%) or affordability of health care (80%). These are closely followed by the future of Medicare and Medicaid (75%) and access to mental health care (70%). About two-thirds of voters say it is “very important” for candidates to discuss immigration (65%), gun violence (65%) and prescription drug costs (64%) while on the campaign trail. For about half of voters, it is “very important” that candidates discuss the opioid crisis (53%), abortion (52%), the future of the ACA (49%), and climate change (48%), while fewer say it is “very important” for candidates to discuss aid to foreign countries (44%). On the other hand, fewer than one-fourth (22%) of voters say it is “very important” for candidates to be discussing COVID-19 heading into the 2024 election.

When asked to pick their top issue, four in ten (41%) voters say the “most important” issue for candidates to discuss is inflation, including the rising cost of household expenses. This is about three times the share of voters who say any other issue is the “most important” for candidates to discuss, such as gun violence (14%) or immigration (12%). Fewer voters say the affordability of health care (8%), the future of Medicare and Medicaid (6%), climate change (5%), abortion (4%), access to mental health care (3%), aid to foreign countries (2%), the opioid crisis (1%), prescription drug costs (1%), or the future of the Affordable Care Act are the “most important” topics on the campaign trail.

Partisan voters differ slightly on what issues they want the presidential candidates to discuss on the campaign trail. For Democratic voters, nine in ten say it is “very important” that candidates talk about affordability of health care (90%) and gun violence (89%), followed by about eight in ten who say inflation (81%) and access to mental health care (78%) are “very important.” The list of issues that are important to Republicans differs slightly, with nearly all Republican voters (96%) saying it is “very important” that inflation is discussed, eight in ten (82%) saying immigration is “very important,” and about seven in ten wanting to hear about the affordability of health care (71%) or the future of Medicare and Medicaid (70%).

Further down the list for partisans, some of the most polarized issues are climate change, with Democratic voters 51 percentage points more likely than Republicans to say this is a “very important” issue for candidates to talk about (73% v. 22%). Nearly three-fourths (72%) of Democratic voters say that abortion is a “very important” issue for candidates to discuss, compared to about four in ten (38%) Republican voters who say the same (a 34 percentage point difference). The future of the Affordable Care Act, an issue that was once a key health care issue for Republican voters, is now ranked as a “very important” issue for larger shares of Democratic voters (70%) than Republican voters (32%). This survey was fielded before former President Donald Trump reignited the issue by announcing that he plans to replace the 2010 health care law.

Yet, across partisans and among other key voting groups, inflation emerges among the top issues when voters are asked for their “most important” issue for candidates to discuss. For Democratic voters, Black voters, and voters ages 65 and older, similar shares rank gun violence and inflation as the most important issue. The future of Medicare and Medicaid emerges in the top five issues for adults over age 50, including 13% of adults ages 65 and older, and abortion makes its way into the top five issues for Democratic voters and younger voters.

In the figure below, use the drop-down menu to explore the top five “most important” issues among key subgroups:

When voters are asked which political party they trust to handle each of the issues presented, the Republican Party has a slight edge on inflation and the Democratic Party has the edge on health care related issues, climate change, abortion, and gun violence. Just over half (54%) of voters say they trust the Republican Party to do a better job to address inflation including the rising cost of household expenses, compared to 45% of voters who say they trust the Democratic Party more on this issue. The Republican Party also holds the advantage among voters on immigration (57% v. 41%) and aid to foreign countries (55% v. 41%).

The Democratic Party, however, has the edge on handing health care related issues such as access to mental health care (61% v. 37%), affordability of health care (59% v. 39%), the future of the ACA (59% v. 39%), the future of Medicare and Medicaid (59% v. 40%), abortion (58% v. 41%), and prescription drug costs (57% v. 42%). Nearly two-thirds of voters also say they trust the Democratic Party (63%) over the Republican Party (35%) to address climate change, and more than half (54%) say they trust the Democratic Party over the Republican Party (44%) to do a better job addressing gun violence.

Voters are split on which party they trust to do a better job handling the opioid crisis with half saying they trust the Democratic Party (50%) and a similar share saying they trust the Republican Party (48%).

To explore how key groups rank their top five “most important” issues they want candidates to discuss, and which political party they trust on each of those issues, use the toggles on the figure below:

Abortion in the 2024 Election

After the Dobbs decision overturned Roe v. Wade in June 2022, decisions about abortion access are now left up to the states. In October 2023, a few state elections that included abortion-related ballot measures gave some insight into how voters react when presented directly with ballot questions related to abortion rights.

Overall, most voters say they think abortion should be legal in either “all cases” (29%) or “most cases” (36%), while one in four voters say it should be illegal in most (26%) cases and just one in ten (9%) say it should be illegal in all cases. A majority of Democratic voters, independent voters, women, men, and voters across age, racial, and ethnic groups say that abortion should be legal in all or most cases. A majority of Republican voters (60%)—including 55% of Republican women—say that abortion should be illegal in all or most cases. Currently, abortion is banned in 14 states in the U.S., and limited in an additional 11 states.

Overall, while most voters say that abortion is an important issue they would like 2024 presidential candidates to discuss, few (4%) voters say it is rises to the most important issue to discuss during this campaign. Most Democratic voters (72%), including seven in ten Democratic women, say that abortion is a very important issue for candidates to discuss, as do seven in ten (68%) Black voters and more than half (55%) of Hispanic voters. Yet, it rises to the most important issue for discussion for just one in ten (11%) of Democratic voters, and fewer than five percent of Black or Hispanic voters.

When it comes to which party voters trust to do a better job handling the issue of abortion, majorities across race, ethnicity, and gender say they trust the Democratic Party, as do majorities of Democrats and independents. Republican voters are much more likely to say they trust the Republican Party to handle the issue of abortion (80%), though four in ten (40%) Republican voters who say abortion should be legal in all or most cases say they trust the Democratic Party more on this issue. For these voters, just one-fourth say abortion is a very important issue to them.

While few voters identify abortion as the most important issue for candidates to discuss, it does appear that the issue could influence a small group of voters’ decisions during the 2024 election. While most voters (57%) say a candidate’s position on abortion is just one of many important factors, one in four (24%) voters say they would only vote for a candidate who shares their views on abortion. Larger shares of Democratic voters (33%) say they would only vote for a candidate who shares their view on abortion, including three in ten (31%) Democratic women. Overall, about one in five voters (19%) say abortion is not an important factor in their vote choice including about three in ten (29%) Republican women.

Abortion does not seem to be a deciding issue in determining which candidates to support for many Republicans, especially those Republicans who think abortion should be legal in all or most cases. Just 4% of this group say they would only vote for a candidate who shares their views on abortion, while half (53%) of Republicans who say abortion should be legal say “a candidate’s position on abortion is just one of many important factors” and four in ten say abortion is not an important factor in their vote choice. This is compared to the nearly three in ten Republican voters who think that abortion should be illegal in all or most cases who say that they would only vote for a candidate who shares their views on abortion.

Many Voters are Pessimistic Heading into the 2024 Election

Less than one year until the 2024 election, many voters are not feeling confident with the way things are going in the U.S. Eight in ten (81%) voters say that things in this country “have gotten off on the wrong track,” compared to about one in five (18%) who say things are generally going in the right direction. While this finding is consistent with past polling of voters since 2014, the latest KFF poll shows that Democratic voters are less pessimistic than Republican voters, with about one-third of Democratic voters saying things in the U.S. are generally going in the right direction (32%) and just six percent of Republican voters saying the same.

Voters who say that things in the U.S. have gotten off on the wrong track are most interested in hearing about inflation, including the rising cost of household expenses (46%), from 2024 presidential hopefuls. About six in ten (62%) of these pessimistic voters say they trust the Republican party better to address inflation and the rising cost of household expenses, while about four in ten (37%) say they trust the Democratic Party on this issue. Voters who say things in the U.S. are headed in the right direction are most interested in hearing about gun violence (24%) and inflation (21%), and larger shares say they trust the Democratic Party on each of these issues.

Medicaid Unwinding and the Inflation Reduction Act (IRA)

Enacted at the start of the pandemic, the Families First Coronavirus Response Act (FFCRA) required state Medicaid programs to keep people enrolled throughout the COVID-19 public health emergency (PHE). However, the Consolidated Appropriations Act (CAA) ended continuous enrollment on March 31, 2023, and required states to conduct redeterminations for all Medicaid enrollees by the end of May 2024. As of November 27, 2023, more than 11 million people have been disenrolled from Medicaid, and by KFF estimates, up to 24 million people could be disenrolled from Medicaid during this period of unwinding of the continuous enrollment provision. Just over half (53%) of U.S. adults say they have heard at least “a little” about states removing adults and children from Medicaid as the pandemic policies end, while half (47%) have heard nothing at all about this. Adults who are currently on Medicaid are most likely to say they have heard of this (65%).

Many states are working to support their Medicaid enrollees in the active renewal process, but enrollees may face barriers renewing Medicaid enrollment. Among those who have heard at least a little about the issue of Medicaid unwinding, a large majority are very (42%) or somewhat (46%) concerned about more adults and children becoming uninsured because of problems obtaining and renewing their coverage through Medicaid. Adults with household incomes under $40,000 and those currently on Medicaid are the most likely to say they are very concerned.

Inflation Reduction Act

More than a year after being signed into law, few adults are aware of the prescription drug regulations included in the Inflation Reduction Act (IRA). About one-fourth are aware that there are federal laws in place that cap monthly insulin costs at $35 for people with Medicare (26%) or that place a limit on annual out-of-pocket drug costs for people with Medicare (23%), and even fewer adults are aware there is a law in place that penalizes drug companies for increasing prices faster than the rate of inflation for people with Medicare (13%). These shares are relatively unchanged from when KFF first explored this in July 2023. However, slightly larger shares of adults now than in July say they are aware that there is a federal law in place that requires the federal government to negotiate the price of some prescription drugs for people with Medicare (32% v. 25% in July). This may be related to the media coverage of the recent announcement by HHS regarding the first 10 drugs covered under Medicare Part D selected for negotiation.

While adults ages 65 and older are more likely to say they are aware of the Inflation Reduction Act’s cap on the cost of insulin for people with Medicare (44%) than younger adults, majorities are still unaware of these provisions. Few seniors are aware that there is a federal law requiring the federal government to negotiate drug costs (36%), placing an annual limit on out-of-pocket drug costs (25%), or penalizing drug companies for increasing prices faster than the rate of inflation for people with Medicare (8%).

This KFF Health Tracking Poll/COVID-19 Vaccine Monitor was designed and analyzed by public opinion researchers at KFF. The survey was conducted October 31- November 7, 2023, online and by telephone among a nationally representative sample of 1,301 U.S. adults in English (1,222) and in Spanish (79). The sample includes 1,016 adults (n=52 in Spanish) reached through the SSRS Opinion Panel either online (n=991) or over the phone (n=25). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails.

Another 285 (n=27 in Spanish) interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame.

Respondents in the phone samples received a $15 incentive via a check received by mail, and web respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card). In order to ensure data quality, cases were removed if they failed attention check questions in the online version of the questionnaire, or if they had over 30% item non-response, or had a length less than one quarter of the mean length by mode. Based on this criterion, one case was removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population based on parameters derived from the Census Bureau’s 2022 Current Population Survey (CPS), 2021 Volunteering and Civic Life Supplement data from the CPS, and the 2023 KFF Benchmarking survey with ABS and prepaid cell phone samples. The demographic variables included in weighting for the general population sample are sex, age, education, race/ethnicity, region, education, civic engagement, internet use, and political party identification by race/ethnicity. The sample of registered voters was weighted separately to match the U.S. registered voter population using the parameters above plus recalled vote in the 2020 presidential election by county quintiles grouped by Trump vote share. Both weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample and registered voters is plus or minus 4 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.

Immigration has been a hot-button issue in U.S. political debate for decades, with policymakers trying to balance economic, security, and humanitarian concerns, and candidates on both sides using immigration talking points to appeal to their base. Immigration policy at the federal level has often shifted dramatically between presidential administrations, and enforcement differs between states. However, debates over immigration policies, including those that restrict or promote pathways to citizenship and access to benefits for undocumented immigrants, often leave out the viewpoints of immigrants themselves, and in some cases, immigrant feel they are treated as pawns in a political game.

A majority of immigrants are naturalized citizens (58%) and thus eligible to vote in U.S. elections, but their views are not often explored in polls of the general public. Immigrants who are noncitizens may have other ways to influence the U.S. political process, but many face language barriers and immigration-related fears that make it difficult for them to engage in the political process.

The Survey of Immigrants, a partnership between KFF and The Los Angeles Times, is the largest nationally representative survey focused on immigrants, interviewing 3,358 immigrant adults in 10 languages. This report focuses on the political engagement, attitudes, and policy preferences of the growing immigrant population in the U.S.

Highlights

• Most immigrants (62%) say they pay attention to politics and government in the U.S. a least a “fair amount,” though few (17%) say they pay “a lot” of attention. Older immigrants, naturalized citizens and those who are English proficient are among the most likely groups of immigrants to say they pay a lot of attention to U.S. affairs.
• Immigrants, including naturalized citizens, lean more towards the Democrats when asked which political party represents their own views, which party best represents the interests of immigrants overall, and whether immigrants were better off under the Biden or Trump presidencies.
• However, many immigrants do not feel that their views or the interests of immigrants generally are well represented by either of the two major U.S. political parties, and half of all immigrants say that who the president is makes no difference in the lives of immigrants.
• Like most U.S.-born adults, a large majority (79%) of immigrant adults support allowing undocumented immigrants who were brought to the U.S. as children to apply for citizenship. A smaller majority of immigrants (59%) also supports allowing undocumented immigrants to sign up for government-sponsored health insurance, though immigrants who are naturalized citizens are split on this question and a majority (69%) of U.S.-born adults are opposed.

Attention to Politics and Political Leanings of Immigrants

Most immigrants report paying at least some attention to U.S. politics, with those who are older, English proficient, and naturalized citizens being the most engaged. About six in ten (62%) immigrants say they follow politics and government in the U.S. a lot (17%) or a fair amount (45%), with majorities across age and immigration statuses saying they follow it at least a fair amount. Immigrants ages 65 and older, naturalized citizens, and immigrants who speak English at least “very well” are most likely to report that they pay “a lot” of attention to politics and government in the U.S.

Twice as many immigrants say that immigrants in general are better off under a Biden presidency than a Trump presidency, but about half say who the president is makes no difference in the lives of immigrants. One in three (33%) say immigrants are better off under Biden, and one in six (16%) say immigrants were better off under Trump.

Immigrants who say they follow U.S. politics “a lot” or “a fair amount” are more likely than those who do not to say who the president is makes a difference, yet across levels of political interest, immigrants lean towards President Biden when asked which recent president was better for immigrants. While, unsurprisingly, six in ten immigrants who say they are best represented by the Democratic Party say immigrants are better off under Biden and about half (53%) of Republican-identifying immigrants say immigrants are better off under Trump, one-third of immigrants who say they are best represented by either the Democrats (34%) or Republicans (32%) say it “makes no difference” who the president is.

Larger shares of immigrants say that the Democratic Party represents their own personal political views better than the Republican Party. Immigrants overall are twice as likely to say that the Democratic Party (32%) represents their political views better than the Republican Party (16%). However, this still leaves about half of immigrants saying that neither party (25%) best represents their views or that they are not sure (27%). Majorities of undocumented immigrants (76%), recent immigrants (67%), immigrants who do not pay attention to U.S. politics (65%), and younger immigrants (ages of 18 and 29) (65%) say they are “not sure” or that neither party represents their political views.

Immigrants differ by race and ethnicity on their partisan leanings, with Hispanic, Asian, and Black immigrants leaning towards the Democratic Party and White immigrants more evenly split between saying the Democratic and Republican parties best represent their views. Across racial and ethnic groups, large shares—between four in ten and six in ten—say neither party best represents them or that they are not sure.

Although more Hispanic immigrants say they feel better represented by the Democratic Party, there are some differences by country or region of origin. Immigrants from South America (18%), Central America (15%), and the Caribbean (18%) are about twice as likely as those from Mexico (7%) to say the Republican Party best represents their political views. Roughly equal shares—three in ten—across these countries and regions say they feel represented by the Democrats, though larger shares of immigrants from Central America (41%) and Mexico (38%) say they are “not sure” which party better represents their views compared to those from South America (26%) or the Caribbean (23%). Among immigrants from Asia, there are few differences by country or region of origin.

Immigrants in California are more likely to say the Democratic party represents their views (36%) while a smaller share in Texas says the same (25%). Yet in both states, about three in ten immigrants say they are not sure and about one in four say neither party better represents their political views.

Nearly half of immigrants (46%) say they think the Democratic Party represents the interests of immigrants at least “somewhat well,” more than twice the share who say the same about the Republican Party (20%). Immigrants across immigration statuses are more likely to say the Democratic Party represents immigrants’ interests well than the Republican Party. Three in ten say they are “not sure” about how well the Republican (33%), or Democratic (31%) Parties represent the interests of immigrants. Noncitizens are more likely to say they are “not sure” how well each of the political parties represent the interests of immigrants.

Attitudes Towards Immigration Policies

Immigrants have mixed views in their assessments of whether U.S. enforcement of immigration laws is too tough or not tough enough, which stands in stark contrast to the views of U.S.-born adults.¹  About one in five immigrant adults say the U.S. is “too tough” (19%) and a similar share say the U.S. is “not tough enough” (18%) in enforcing immigration laws, while about one-fourth (27%) say enforcement is “about right,” and about one-third (35%) say they are not sure. U.S.-born adults are much more likely to say that enforcement of these laws is “not tough enough” (52%), while one in six say enforcement is “too tough” (15%) or “about right” (14%). Immigrants vary somewhat in their assessments of immigration enforcement by immigration status, as naturalized citizens are somewhat more likely to say the U.S. is not tough enough in enforcement, while those who are likely undocumented are more likely to say they are “not sure.”

Immigrants’ views on U.S. enforcement of immigration laws are also largely divided by their political leanings. Immigrants who say their views are best represented by the Democratic Party (referred to here as Democratic-leaning) are more likely than Republican-leaning immigrants or immigrants who do not feel represented by either political party to say that enforcement in the U.S. is “too tough” (29%). Republican-leaning immigrants are most likely to say that enforcement in the U.S. is “not tough enough” (48%). However, many immigrants are not sure if immigration enforcement in the U.S. is too tough or not, including about one in four Democratic-leaning (26%) immigrants, one in five Republican-leaning (22%) immigrants and 45% of immigrants who do not have a political leaning.

The idea of allowing undocumented immigrants who were brought to the U.S. as children to apply for citizenship is widely popular, with about eight in ten immigrants (79%) and two-thirds of U.S.-born adults saying this is a “good idea.” This proposal has been introduced to Congress in a variety of forms over the past two decades as The Development, Relief, and Education for Alien Minors Act, or DREAM Act, but has failed to pass. Immigrants across partisan affiliation and citizenship status largely support the policy, though fewer (55%) Republican-leaning immigrants say this is a good idea. Under the Deferred Action for Childhood Arrivals (DACA) program created in 2012, eligible young adults who were brought to the U.S. as children can receive protection from deportation and work authorization for temporary, renewable periods. However, DACA does not provide a pathway to U.S. citizenship, and the federal government is not currently processing new DACA requests due to court orders.

While a majority of immigrants support allowing undocumented immigrants to sign up for government-sponsored health insurance, a majority of U.S.-born adults say this is a “bad idea.” Nearly twice the share (59%) of immigrants than U.S.-born adults (30%) say this policy is a “good idea.” Even still, immigrants are split by immigration status and partisan affiliation on their support for this policy. Immigrants who are likely undocumented or lawfully present are more likely to say this policy is a “good idea” (85% and 68%) while naturalized citizens are split, with half saying it is a “good idea” (49%) and half saying it is a “bad idea” (48%). Similar shares of Democratic-leaning immigrants say the policy is a good idea (71%) and Republican-leaning immigrants say it is a bad idea (71%).

Notably, these questions did not offer arguments for or against the policies, and support may be higher or lower in a more contextualized situation.

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.

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.

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.

1. u00a0u00a0Supplemental to the Survey of Immigrants, KFF also conducted a representative survey of 1,049 U.S.-born adults. to compare the immigrant and native-born experience. KFF/LA Times Survey of Immigrants: U.S. Born Adult Comparison (June 29 u2013 July 9, 2023). ↩︎