Key Takeaways

• Funding for Medicare, which totaled $1 trillion in 2023, comes primarily from general revenues (government contributions), payroll tax revenues paid by employers and workers, and premiums paid by beneficiaries.
• Based on current projections from the Medicare Board of Trustees’ 2024 report, the Medicare Part A (Hospital Insurance, or HI) trust fund is projected to be depleted in 2036, 12 years from now – an improvement of five years compared to the projected depletion date of 2031 in the previous report due to higher expected revenues and lower projected spending. To date, lawmakers have never allowed the HI trust fund to be fully depleted.
• Total Part A spending is projected to exceed revenues beginning in 2030, which means trust fund reserves will be needed to pay benefits in full. By 2036, there will be insufficient revenues, including reserves, to pay full benefits for the year. Medicare would be able to pay 89% of costs covered under Part A using payroll tax revenues in that year.
• The revenues for Medicare Parts B and D are determined annually to meet expected spending obligations for the coming year, meaning that the Supplementary Medical Insurance, or SMI, trust fund does not face a funding shortfall, in contrast to the HI trust fund. But higher projected spending on Part B and Part D will increase the amount of general revenues and beneficiary premiums required to cover this spending. Altogether, beneficiary premiums and cost sharing for Part B and Part D are estimated to account for 26% of the average Social Security benefit in 2024.
• With rising enrollment in Medicare Advantage, payments to Medicare Advantage plans are rising as a share of Part A and Part B spending, which affects the balance of the HI Trust Fund and Part B premiums. In 2024, MedPAC estimates that the Medicare program will spend 22% more per Medicare Advantage enrollee than for similar beneficiaries in traditional Medicare – an additional $83 billion in total.
• The Medicare trustees estimate that an increase of 0.35% of taxable payroll (increasing the 2.9% payroll tax to 3.25%) or a spending reduction of 8% would bring the HI trust fund into balance over the long term.

Introduction

Medicare, the federal health insurance program for 67 million people ages 65 and over and younger people with long-term disabilities, helps to pay for hospital and physician visits, prescription drugs, and other acute and post-acute care services. In 2023, Medicare benefit payments totaled $839 billion, net of premiums and other offsetting receipts. Accounting for 21% of national health care spending and 12% of the federal budget in 2022, Medicare spending often plays a major role in federal health policy and budget discussions.

In discussions of Medicare’s financial condition, attention frequently centers on one specific measure —the solvency of the Medicare Hospital Insurance (HI) trust fund, out of which Medicare Part A benefits are paid. Based on current projections from the Medicare Board of Trustees in their 2024 report, the HI trust fund is projected to be depleted in 2036, 12 years from now – an improvement of five years compared to the projected depletion date of 2031 in the previous report due to higher expected revenues and lower projected spending.

The HI trust fund depletion date is only one way of measuring Medicare’s financial status and doesn’t present a complete picture of total program spending and revenues, but it does indicate whether there is an imbalance between spending and financing for inpatient hospital and other benefits covered under Medicare Part A. These FAQs answer key questions about Medicare financing and trust fund solvency.

How is Medicare financed?

Funding for Medicare, which totaled $1 trillion in 2023, comes primarily from general revenues (government contributions), payroll tax revenues paid by employers and workers, and premiums paid by beneficiaries (Figure 1). Other sources include taxes on Social Security benefits, payments from states, and interest. The different parts of Medicare are funded in varying ways, and revenue sources dedicated to one part of the program cannot be used to pay for another part.

• Part A, which covers inpatient hospital stays, skilled nursing facility (SNF) stays, some home health visits, and hospice care, is financed primarily through a 2.9% tax on earnings paid by employers and employees (1.45% each). Higher-income taxpayers (more than $200,000 per individual and $250,000 per couple) pay a higher payroll tax on earnings (2.35%). Payroll taxes accounted for 88% of Part A revenue in 2023.
• Part B, which covers physician visits, outpatient services, preventive services, and some home health visits, is financed primarily through a combination of general revenues (71% in 2023) and beneficiary premiums (27%) (and 1% from interest and other sources). Beneficiaries with annual incomes over $103,000 per individual or $206,000 per couple pay a higher, income-related Part B premium reflecting a larger share of total Part B spending, ranging from 35% to 85%. The standard monthly Part B premium in 2024 is $174.70, while the income-related monthly premiums range from $244.60 to $594.
• Part D, which covers outpatient prescription drugs, is financed primarily by general revenues (73%), with additional revenues coming from beneficiary premiums (14%) and state payments for beneficiaries enrolled in both Medicare and Medicaid (12%). Higher-income enrollees pay a larger share of the cost of Part D coverage, as they do for Part B.

The Medicare Advantage program (Part C) is not separately financed. Medicare Advantage plans, such as HMOs and PPOs, cover Part A, Part B, and (typically) Part D benefits. Funds for Part A benefits provided by Medicare Advantage plans are drawn from the Medicare HI trust fund (accounting for 48% of total spending on Part A benefits in 2023). Funds for Part B and Part D benefits are drawn from the Supplementary Medical Insurance (SMI) trust fund. Beneficiaries enrolled in Medicare Advantage plans pay the Part B premium and may pay an additional premium for their plan.

What does Medicare trust fund solvency mean and why does it matter?

The solvency of the Medicare Hospital Insurance (HI) trust fund, out of which Part A benefits are paid, is a common way of measuring Medicare’s financial status, though because it only focuses on the status of Part A, it does not present a complete picture of total program spending. Medicare solvency is measured by the level of reserves in the HI trust fund. In years when annual income to the trust fund exceeds benefits spending, the level of reserves increases, and when annual spending exceeds income, the level of reserves decreases. This matters because when spending exceeds income and the reserves are fully depleted, Medicare will not have sufficient funds to pay hospitals and other providers for all Part A benefits that are provided in a given year. Based on current projections from the Medicare trustees, Part A spending will exceed Part A revenues beginning in 2030.

When are HI trust fund reserves projected to be depleted?

Each year, the Medicare trustees provide an estimate of the year when the HI trust fund reserves are projected to be fully depleted. In the 2024 Medicare Trustees report, the trustees project that reserves in the Part A trust fund will be depleted in 2036, 12 years from now. This is an improvement of five years from the projection in the 2023 Medicare Trustees report, when the depletion date was projected to be 2031 (Figure 2).

In the coming decade, based on current projections from the Medicare trustees, Part A spending will exceed Part A revenues beginning in 2030, leading to a gradual reduction in the level of reserves in the HI trust fund (Figure 3). By 2033, the Medicare trustees project that the HI trust fund will begin the year with $254 billion in reserves, but because spending is projected to exceed revenue by $55 billion that year, the trust fund is expected to end the year with $198 billion in reserves. As Part A spending is projected to continue to exceed Part A revenues in the years that follow, the reserves will be depleted at some point during the year in 2036.

What happens if the reserves in the HI trust fund are fully depleted? Can Medicare go bankrupt?

Medicare cannot go bankrupt or go broke. While some describe Medicare or the Medicare HI trust fund as heading toward bankruptcy or going broke when referring to the depletion of HI trust fund reserves, Medicare will not cease to operate if HI trust fund reserves are fully depleted because revenue will continue flowing into the fund from payroll taxes and other sources.

Based on current projections of trust fund reserve depletion in 2036, Medicare would be able to pay 89% of costs covered under Part A using payroll tax revenues in that year. However, there is no automatic process in place or precedent to determine how to apportion the available funds or how to fill the shortfall.

What factors affect the solvency of the HI trust fund and what explains the improved status in 2024?

The solvency of the Medicare HI trust fund is affected by several factors. In addition to legislative and regulatory changes that affect Part A spending (both utilization of services and payments for services provided by hospitals, skilled nursing facilities, and other providers, and for Part A services covered by Medicare Advantage plans) and revenues, Part A trust fund solvency is affected by:

• the level of growth in the economy, which affects Medicare’s revenue from payroll tax contributions: economic growth that leads to higher employment and wages boosts revenue to the trust fund, while an economic downturn can have the opposite effect,
• overall health care spending trends: higher health care price and cost growth can lead to higher spending for services covered under Medicare Part A that could hasten the depletion date, while moderation in the growth of prices and costs could slow spending growth, and
• demographic trends: this includes the aging of the population, which is leading to increased Medicare enrollment (especially between 2010 and 2030 when the baby boom generation reaches Medicare eligibility age); a declining ratio of workers per beneficiary making payroll tax contributions, which means lower revenue; and other factors, such as fertility rates, disability rates, and immigration.

In the 2024 report, the Medicare trustees attributed the improvement in the financial status of the HI trust fund to a combination of factors:

• Income to the HI trust fund is projected to be higher than in the 2023 report due to higher employment and average wage growth.
• Part A spending is projected to be lower than last year’s estimates due to a policy change to exclude graduate medical education expenses associated with enrollees in Medicare Advantage from the fee-for-service costs used to determine payments to Medicare Advantage plans.
• Projected Part A spending on inpatient and home health services is lower than previously estimated, with more recent spending data informing these projections.

How have the solvency projections of the HI trust fund changed over time?

Since 1990, the HI trust fund came within 10 years of depletion for much of the 1990s, in 2009, and again in each year between 2018 and 2023 (Figure 4). To improve the fiscal outlook of the trust fund in the 1990s, Congress enacted legislation to reduce Medicare spending obligations, while policy changes adopted in the Affordable Care Act of 2010 – including reduced Medicare payments to plans and providers and increased revenues – helped to improve the status of the HI trust fund between 2009 and 2010. To date, lawmakers have never allowed the HI trust fund to be fully depleted.

What is the Medicare funding warning and why does it matter?

The Medicare Modernization Act of 2003, the law that created the Medicare Part D drug benefit, also included a provision that required the Medicare Trustees to calculate annually whether the difference between total Medicare outlays and specified dedicated financing sources is expected to account for more than 45% of Medicare outlays in the current fiscal year or any of the next six fiscal years. If so, the trustees issue a determination of “excess general revenue Medicare funding,” and making such a determination in two consecutive reports triggers a “Medicare funding warning.”

In their 2024 report, the Medicare Trustees made a determination of “excess general revenue Medicare funding” based on projections of general revenue funding exceeding 45% in the next seven years, and because the same determination was made in the 2023 report, this triggered a “Medicare funding warning” (Figure 5). In fact, the trustees have made a determination of excess general revenue funding for eight years in a row and issued funding warnings for seven years in a row.

While this measure is intended to draw attention to Medicare spending and revenues and the role of government contributions in funding the Medicare program, no automatic changes are made to Medicare if the funding warning is issued. Instead, the President is required to submit legislation to Congress to respond to the warning, and an expedited process is in place for the Congress to consider the President’s proposed legislation. To date, however, only President George W. Bush in 2008 submitted a proposal to Congress in direct response to a Medicare funding warning issued by the Medicare Trustees in 2007, but Congress took no action on that proposal.

Are Medicare Part B and Part D also facing a trust fund shortfall?

The Hospital Insurance trust fund provides financing for only one part of Medicare, so it represents only one part of Medicare’s total financial picture. While Part A is funded primarily by payroll taxes, benefits for Part B physician and other outpatient services and Part D prescription drugs are funded by general revenues (government contributions) and premiums paid for out of separate accounts in the Supplementary Medical Insurance, or SMI, trust fund. The revenues for Medicare Parts B and D are determined annually to meet expected spending obligations for the coming year, meaning that the SMI trust fund does not face a funding shortfall, in contrast to the HI trust fund.

However, higher projected spending for benefits covered under Part B and Part D will increase the amount of general revenues and beneficiary premiums required to cover costs for these parts of the Medicare program in the future. The Medicare trustees project that the standard monthly Part B premium will increase from $174.70 in 2024 to nearly $300 in 2033, accounting for 15% of the average retired worker’s Social Security benefit in 2033, up from 10% in 2024. Altogether, premiums and cost sharing for Part B and Part D are estimated to account for 26% of the average Social Security benefit in 2024.

How do payments to Medicare Advantage plans affect the solvency of the Part A Trust Fund and Part B premium and general revenue spending?

With the rise in Medicare Advantage enrollment, payments to private Medicare Advantage plans account for a growing share of total Medicare spending under Part A and Part B. According to current projections, payments to Medicare Advantage plans are projected to rise as a share of total Part A spending from 48% in 2023 to 54% in 2033, a shift that could impact HI trust fund solvency. Medicare Advantage is also projected to rise as a share of total Part B spending, from 55% in 2023 to 65% in 2033, which could impact both beneficiary premiums and general revenue spending. In 2024, MedPAC estimates that the Medicare program will spend 22% more per Medicare Advantage enrollee than for similar beneficiaries in traditional Medicare – an additional $83 billion in total.

What is the longer-term outlook for Medicare financing and trust fund solvency?

Although current projections show that the short-term solvency outlook for the Medicare HI trust fund has improved, the Medicare program continues to face longer-term financial pressures associated with higher health care costs and an aging population. The Medicare trustees estimate that an increase of 0.35% of taxable payroll (increasing the 2.9% payroll tax to 3.25%) or a spending reduction of 8% would bring the HI trust fund into balance over the long term.

To sustain Medicare for the long run, policymakers may consider adopting broader changes to the program that could include both reductions in payments to providers and plans or reductions in benefits, and additional revenues, such as payroll tax increases or new sources of tax revenue. Evaluating such changes would likely involve careful deliberation about the effects on federal expenditures, the Medicare program’s finances, and beneficiaries, health care providers, and taxpayers.

As of May 21, 2024, KFF tracking shows that half of all U.S. states have enacted a law that prohibits or limits youth access to gender affirming care. The uptick in this lawmaking was slow at first but then rapidly accelerated over the course of the past 18 months. LGBTQ civil rights, including those related to health care access, continue to be the subject of divisive political debates at the state and national level, particularly as the election season heats up.

Figure 1

Arkansas was the first state to enact a youth gender affirming care ban in April 2021, with Arizona and Alabama following about a year later. Beginning in January 2023, the number of states enacting these policies rapidly proliferated and by August, the number of states with bans reached 22 – a seven-fold increase in an eight-month period. As of last week, the total number of states has now reached 25.  While these laws do mainly impact youth access to health care, some impact adult access too, and a majority of the laws (23 of 25) include professional and/or civil penalties for health care practitioners who provide such care, including six states with felony penalties. Similar to the proliferation of bans, legal challenges are piling up, and laws in 17 of the 25 states are being challenged in state or federal court. (Detailed information about these state laws and litigation available in our Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions, which KFF will continue to update as developments occur.)

Oral health is key to overall health and well-being, and the use of dental services helps prevent and treat dental disease and improves oral health. While sometimes overlooked as a cosmetic issue, oral health encompasses the health of the entire mouth, which in turn supports the health of the rest of the body. Despite the importance of dental services, oral health conditions such as tooth decay, gum disease, tooth loss, and oral cancer, are common, with data showing that over a quarter of adults and more than one in ten children have untreated dental caries (or tooth decay). Untreated oral health conditions can have adverse effects on overall quality of life, impacting a person’s ability to eat, speak, sleep, socialize and participate in everyday activities such as school or work, and are associated with other chronic conditions such as heart disease and diabetes. Without access to regular, appropriate dental services, untreated oral health conditions can lead to less effective and more expensive emergency care and cost the U.S. about $45 billion each year in lost productivity.

The prevalence of unmet oral health needs is higher among people with low incomes, including those with Medicaid. Almost one-fourth of children with household incomes below 100% of the federal poverty level (FPL) have one or more oral health problems, and low-income children are more likely to report problems than children in higher income households (Figure 1). Low-income adults also have more unmet dental health care needs when compared with higher income adults. In part, reflecting these income differences, people of color are more likely to experience oral health problems and are less likely to receive dental care compared with White individuals. People living in rural areas also experience worse oral health outcomes and have more difficulty accessing care than those living in urban areas. Medicaid covers a majority of nonelderly people living in poverty and over half of Black, Hispanic, and American Indian and Alaska Native (AIAN) children, making Medicaid an important tool for improving oral health and addressing oral health disparities.

This issue brief describes Medicaid dental coverage, examines the use of dental services for children and adults in Medicaid, and discusses current challenges and policy changes that impact access to oral health care for Medicaid enrollees. The analysis uses Medicaid claims data which track the services enrollees use and may differ from survey data (see Methods and Appendix Table 1). Key takeaways include:

• Dental services must be covered for all children in Medicaid under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, but dental services for adults are an optional Medicaid benefit that states can elect to cover.
• Nearly half of children covered by Medicaid or CHIP receive at least one dental service within the year compared with only one-fifth of adult Medicaid enrollees, reflecting differences in coverage policies for children and adults.
• While similar shares of adult Medicaid enrollees receive at least one dental service within the year across racial and ethnic groups, Hispanic and Asian children enrolled in Medicaid or CHIP have the higher rates of dental service use compared to other groups. In addition, the share of children and adults enrolled in Medicaid or CHIP receiving at least one dental service within the year is slightly lower in rural areas compared with urban areas.
• Rates of dental service use among Medicaid adults are higher in states with more extensive Medicaid dental coverage policies and range from under 5% in Alabama and Tennessee to over 30% in Montana, Minnesota, Connecticut, Massachusetts, and New Jersey. Rates of dental service use among children, which are generally higher, also vary substantially by state, ranging from under 40% in Illinois, Ohio, North Dakota, and Wisconsin to over 60% in Montana, Connecticut, and Texas.
• Rates of dental service use among both children and adults with Medicaid or CHIP declined during the pandemic and had not rebounded to pre-pandemic levels as of 2021.
• Enrollees likely face a number of barriers to accessing dental care, including dental workforce shortages in general or a lack of dental providers accepting Medicaid in their community. Focused initiatives could address barriers and disparities in access to dental care. For adults specifically, lack of state Medicaid coverage of dental benefits also impacts rates of dental service use, and expanded coverage could increase access to dental care. Lastly, loss of Medicaid coverage altogether also has implications for access to care, and millions of people have been disenrolled from Medicaid during the unwinding of the continuous enrollment provision.

Does Medicaid cover dental benefits?

State Medicaid programs are required to cover dental services for children under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The EPSDT benefit provides a comprehensive set of health care services, including screening, vision, hearing, and dental services, for children under age 21. States are required to cover all these services as well as any services “necessary… to correct or ameliorate” a child’s physical or mental health condition. These services must be provided for children regardless of whether a state chooses to cover them for adults and on a periodic basis that meets reasonable standards of medical practice. Most states use the American Academy of Pediatric Dentistry (AAPD) periodicity schedule, which recommends a child’s first oral examination at the eruption of their first tooth (no later than 12 months of age) and every six months after.

Dental services for adults 21 and older are an optional benefit in Medicaid, leading to state variation in coverage policies. As of 2022, thirty-nine states and DC covered dental services beyond emergency services for the general adult population (Figure 2). Even more states offer dental benefits beyond emergency services for pregnant enrollees, and some states also have unique dental coverage policies in place for adults eligible based on age (65+) and those eligible based on disability. While most states cover dental services beyond emergency services for adults, the specific services covered and the amount, duration, and scope of services can vary, and managed care plans may provide additional dental benefits beyond state requirements. As the economy changes, state coverage of dental benefits in Medicaid may also change. States have historically added or expanded dental benefits when state fiscal conditions are strong, as a number of state Medicaid programs have done in recent years, but states have also cut dental services when facing budgetary pressures.

How does use of dental services vary by the type of service and other selected characteristics?

Nearly half of children covered by Medicaid or CHIP receive at least one dental service within the year compared with only one-fifth of adults, reflecting differences in coverage policies for children and adults (Figure 3). This means, despite broad coverage of dental benefits, about half of children enrolled in Medicaid or CHIP are not receiving any dental care. The FY 2022 Child Core Set reports also flagged that median state performance on all three dental indicators for oral evaluation, dental sealants, and topical fluoride treatment fell below 50%. Further, rates for preventive dental care are lower than rates for any dental services for both children and adults, with slightly less than half of children receiving preventive dental care (45% in 2021) and about one in ten adults receiving preventive dental care (11% in 2021). Adults are also more likely to receive dental treatment services than preventive services, reflecting the wider availability of emergency or limited dental services than comprehensive dental services for adults.

While similar shares of adults in Medicaid receive at least one dental service within the year across racial and ethnic groups, Hispanic and Asian children enrolled in Medicaid or CHIP have the highest rates of dental service use (56% and 50%, respectively) compared to other racial and ethnic groups (Figure 4). Native Hawaiian and Pacific Islander (NHPI) and AIAN children enrolled in Medicaid or CHIP have the lowest rates of dental service use (43% and 44%, respectively). This is similar to findings for well-child visits found in a prior KFF analysis. For adults, about one-fifth of enrollees in each racial and ethnic group used at least one dental service within the year. These findings, which are based on claims data from 35 states, may differ from those based on survey data (Appendix Table 1) and may reflect that some services received from Indian Health Service providers are not captured in the analysis (see Methods). Sixteen states were excluded from the race and ethnicity analysis due to data quality issues.

The share of children and adults enrolled in Medicaid or CHIP receiving at least one dental service within the year is slightly lower in rural areas compared with urban areas (Figure 4). Dental service use rates in rural areas in 2021 were 3 percentage points less in than urban areas for both children and adults. Note that only 18% of children and 17% of adults in the analysis lived in a rural area, and three states were excluded from the geographic area analysis due to data quality issues (see Methods).

How does dental service use vary across states?

While rates of dental service use among adults are relatively low across all states, rates are higher in states with more extensive Medicaid dental coverage policies (Figure 5). The share of adults using any dental services ranges from under 5% in Alabama and Tennessee to over 30% in Montana, Minnesota, Connecticut, Massachusetts, and New Jersey. This means that, even in the state with the highest rate, almost two-thirds of adults are not receiving any dental care within the year. In addition, a number of states with extensive dental benefits for Medicaid adults have rates below the median (21%), signaling that even with expansive coverage there may still be issues related to access to dental care in those states.

The share of Medicaid children using any dental services within the year varies substantially by state despite broad coverage of dental benefits under Medicaid’s EPSDT benefit (Figure 6). The share of children using any dental services ranges from under 40% in Illinois, Ohio, North Dakota, and Wisconsin to over 60% in Montana, Connecticut, and Texas. Almost a third of states (14 states) had dental service use rates below the median for both children and adults, which could point to access related issues in those states such as limited provider availability, other access barriers, as well as limited coverage policies for adults.

How did dental service use change during the pandemic?

Rates of dental service use among both children and adults with Medicaid or CHIP declined during the pandemic (Figure 7). The share of children using any dental service declined 8 percentage points from 2019 to 2020 (from 52% to 44%), and the share of adults using any dental services declined by 5 percentage points (from 24% to 19%). For both age groups, dental service use rates began to rebound in 2021, but remained below 2019 levels. The pandemic broadly impacted service utilization, and it remains unclear the extent to which dental service use rates will continue to rebound or where gaps will remain.

What are current challenges and strategies to expand access to dental care?

Rates of dental service use for both children and adults in Medicaid or CHIP are low, indicating enrollees likely face barriers to accessing dental care, including a lack of available dental providers in their community. Almost 60 million people in the U.S. live in a dental health workforce shortage area, and there is substantial variation in dental provider availability by state. Though dentist participation measures vary, one study found over half of dentists also do not accept Medicaid, and some who do may only treat a small number of Medicaid patients or may not be accepting new Medicaid patients. Low Medicaid reimbursement rates for dental services contribute to this issue, limiting the number of providers that are willing to take Medicaid. Medicaid/CHIP enrollees can experience other barriers when accessing health care that can also impact utilization rates such as lack of transportation, language barriers, disabilities, and difficulty finding childcare or taking time off for an appointment. These barriers, in addition dental provider participation in Medicaid and reimbursement rates, all have implications for access to dental care. Recent state efforts to address dental workforce issues could help expand access to dental care and increase use of dental services.

Recent federal actions could also help promote access to quality dental care for children. A Government Accountability Office (GAO) report found that many Medicaid-covered children do not receive recommended EPSDT screenings and services, including dental services, and recommended increased CMS oversight of EPSDT. In response, the Bipartisan Safer Communities Act included a number of Medicaid/CHIP provisions to ensure access to comprehensive health services and strengthen the EPSDT benefit, including updated guidance on state EPSDT implementation (expected by June 2024). In 2024, it also became mandatory for states to report the Child Core Set, a set of physical and mental health quality measures, with the goal of improving health outcomes for children. Lastly, all states as of January 2024 are now required to provide 12-month continuous eligibility for children enrolled in Medicaid and CHIP, which could help children remain connected to care, including dental care. Some states are also extending continuous eligibility for children in Medicaid for multiple years, which could help children maintain coverage beyond one year.

NHPI and AIAN children, enrollees in rural areas, and enrollees in certain states have the lower rates of dental service use, indicating focused initiatives may be needed to address disparities in access to dental care. Tackling access challenges including dental workforce issues, addressing the social determinants of health such as food insecurity, strengthening community outreach programs, and expanding dental services provided through Federally Qualified Health Centers (FQHCs) and school-based dental services are all tools that can be used to address oral health disparities. CMS recently released an updated school-based services claiming guide, and states have taken action to expand Medicaid coverage of school-based care in recent years. Public health approaches to improving oral health and preventing cavities are also important for addressing disparities and include school sealant programs for children and community water fluoridation. Despite a robust body of research showing the safety and effectiveness, some localities and states are now reconsidering water fluoridation in their communities amid backlash.

For adults, lack of state Medicaid coverage of dental benefits also impacts rates of dental service use, and expanded coverage could increase access to dental care. As of 2022, only 25 states and DC offer extensive dental benefits in their Medicaid programs to the general adult population (Figure 2). However, several states in KFF’s annual Medicaid budget survey have reported adding comprehensive dental services for adults or other groups, including pregnant individuals or people with disabilities, since then. CMS also recently finalized a rule that allows states to include dental benefits for adults in ACA marketplace plans. Research has shown that expanding dental coverage for adults increases access and use of dental services and is also associated with improved oral health for children. However, even with a robust dental benefits package, securing access to dental providers who accept Medicaid and have availability can still be a challenge, as has been recently seen in North Carolina and Virginia following benefit expansions. Further, when states have faced budget pressures, adult dental services in Medicaid have typically been among some of the first services limited or cut.

Loss of Medicaid coverage altogether also has implications for access to care, and at least 22 million people, including children and adults, have been disenrolled from Medicaid in the past year due to the unwinding of the Medicaid continuous enrollment provision. In some cases, individuals disenrolled from Medicaid may transition to other coverage, but they may also experience a gap in coverage or become uninsured. KFF analysis shows individuals without insurance coverage have lower access to care and are more likely to delay or forgo care due to costs, and research has found dental care to be more unaffordable than other types of health care.

Appendix

A new KFF analysis of our 2023 Survey of Racism, Discrimination, and Health finds that Black (39%) and Hispanic (36%) adults who report fair or poor mental health are less likely than White (50%) adults to say they received mental health services in the past three years.

Such disparities reflect several barriers to mental health care identified by these adults. In addition to cost concerns and being too busy or not being able to get time off to seek care, Hispanic and Black adults also disproportionately report other challenges such as being afraid or embarrassed to seek care, not knowing how to find a provider, or thinking they would be unable to find a provider with a shared background.

The findings come against a backdrop of what other KFF polling and analysis indicates is a national mental health crisis in the wake of the COVID-19 pandemic. People of color have been disproportionately affected by the rises in drug overdose and suicide deaths across the U.S. in recent years. They also are more likely to report experiences of racism and discrimination, which are associated with worse mental health and well-being.

Other key takeaways from the survey include:

• Among adults who received or tried to receive mental health care, Asian (55%), and Black (46%) adults are more likely to report difficulty finding a provider who could understand their background and experiences compared to their White counterparts (38%). Among those who thought they needed mental health care but did not try to find a provider, Hispanic adults are more likely than White adults to say the primary reason was they didn’t know how to find a provider (24% vs. 11%) or that they were afraid or embarrassed to seek care (30% vs. 18%).
• Awareness of the 988 mental health hotline remains low, particularly among Black, Hispanic, and Asian adults. As of Summer 2023, nearly one in five (18%) adults say they have heard a lot or some about 988, with Black (16%), Hispanic (11%), and Asian (13%) adults less likely to say they have heard about 988 than White adults (21%).
• Adults who report unfair treatment or negative experiences with a provider are twice as likely as those without these experiences to say they went without needed mental health care. Four in ten (41%) adults who report they were treated unfairly or with disrespect by a health care provider and about one-third (35%) of adults who say they’ve had at least one negative experience with a health care provider say they did not get mental health services they thought they needed compared to smaller shares of those who do not report these experiences (18% and 15%, respectively).

For more data and analyses based on KFF’s Racism, Discrimination and Health Survey, visit kff.org.

Key Takeaways

In the wake of the COVID-19 pandemic, 90% of U.S. adults say the country is facing a mental health crisis and many reported major impacts of severe mental health problems on their families, according to a KFF/CNN survey. Additionally, drug overdose deaths sharply increased amid the pandemic and suicide deaths rose. People of color have been disproportionately affected by the rises in drug overdose and suicide deaths. People of color also are more likely to report experiences of racism and discrimination, which are associated with worse mental health and well-being. Reports of any mental illness in the past year remain lower among Hispanic, Black, and Asian adults compared to White adults. However, mental illness among people of color may be underdiagnosed due to the lack of culturally sensitive screening tools, coupled with structural barriers to care, with previous research pointing to racial disparities in receipt of mental health services.

This brief examines disparities in mental health care by race and ethnicity and other factors based on data from the 2023 KFF Racism, Discrimination and Health Survey, a large, nationally representative survey based on responses from over 6,000 adults. The survey provides unique data on access to the health care system and how factors such as racism and discrimination impact these experiences and overall health and well-being. Key findings include:

Among adults who report fair or poor mental health, White adults (50%) are more likely to say they received mental health services in the past three years compared with Black (39%) and Hispanic adults (36%). Across racial and ethnic groups, about half of all adults (53%) who report that they received mental health services said they were very or extremely helpful.

Adults identify cost concerns and scheduling difficulties as primary barriers to mental health care, and Hispanic, Black, and Asian adults disproportionately report additional challenges, such as finding a provider who can understand their background and experiences, lack of information, or stigma or embarrassment. Among adults who received or tried to receive mental health care, Asian (55%), and Black (46%) adults are more likely to report difficulty finding a provider who could understand their background and experiences compared to their White counterparts (38%). Among those who thought they needed mental health care but did not try to find a provider, Hispanic adults are more likely than White adults to say the main reason was they didn’t know how to find a provider (24% vs. 11%) and/or that they were afraid or embarrassed to seek care (30% vs. 18%).

Adults who report unfair treatment or negative experiences with a provider are twice as likely as those without these experiences to say they went without needed mental health care. Four in ten (41%) adults who report they were treated unfairly or with disrespect by a health care provider and about one-third (35%) of adults who say they’ve had at least one negative experience with a health care provider say they did not get mental health services they thought they needed compared to smaller shares of those who do not report these experiences (18% and 15%, respectively).

Reported awareness of the 9-8-8 mental health hotline remains low overall, particularly among Black, Hispanic, and Asian adults. As of Summer 2023, about one in five (18%) adults say they have heard a lot or some about 9-8-8, with Black (16%), Hispanic (11%), and Asian (13%) adults less likely to say they have heard about 9-8-8 than White adults (21%). At the same time, about one in five (21%) adults say they or a family member has ever experienced a severe mental health crisis that resulted in serious consequences such as homelessness, hospitalization, incarceration, self-harm, or suicide, with this share rising to 39% among young (ages 18-29) White adults.

Findings from the 2023 KFF Racism, Discrimination and Health Survey highlight barriers to mental health care, including costs and difficulties finding providers, with people of color citing additional challenges such as difficulty finding providers with shared background and experiences, lack of information, and stigma and embarrassment. These findings also point to areas of focus that may help address barriers to mental health care, such as diversifying the mental health care workforce and enhancing knowledge of culturally competent care among mental health care providers. Additionally, focused outreach and education efforts among specific communities may address awareness of mental health resources and stigma associated with mental health care. Findings from the 2023 KFF survey offer insight into the interactions of people of color with the mental health care system at a time when they are experiencing disproportionate increases in deaths by drug overdose and suicide and ongoing impacts of racism and discrimination.

Use of Mental Health Services

Receipt of mental health services varied across demographics and by insurance status leading up to the pandemic. As reported in KFF analyses, prior to the pandemic Black adults with moderate to severe symptoms of anxiety and/or depression were less likely than their White peers to receive mental health services. Similarly, among adults with moderate to severe symptoms of anxiety and/or depression, young adults, men, uninsured individuals, and individuals without a usual source of care were less likely than their respective counterparts to receive mental health services.

The 2023 KFF survey data show that about one quarter (23%) of adults say they have received mental health services from a doctor, counselor, or other mental health professional in the past three years. This share rises to 45% among those who report fair or poor mental health status, compared with about one in five (19%) of those who say they have good to excellent health.

Among adults who report fair or poor mental health, White adults (50%) are more likely to say they received mental health services in the past three years compared with Black (39%) and Hispanic adults (36%) (Figure 1). Additionally, among those who report fair or poor mental health status, U.S.-born adults (48%) are more likely than their immigrant counterparts (26%) to report receiving mental health services, and insured adults with fair or poor mental health status are more likely than those who are uninsured to say they received mental health services (48% vs. 27%).

About half of adults (53%) who report that they received mental health services said they were very or extremely helpful (Figure 2). The remaining 47% said they were somewhat, not too, or not at all helpful. Adults with self-reported fair or poor mental health status were less likely than those with better reported mental health status to say that the services they received were very or extremely helpful (41% vs. 59%), although this could reflect improved self-reported mental health status among those who found the services helpful.

Barriers to Accessing Mental Health Services

Prior research shows that many adults report unmet mental health needs and face barriers to accessing mental health services. Common barriers to accessing mental health care include costs, not knowing where to obtain care, limited provider options, and limited acceptance of insurance among providers. People of color face increased access barriers due to a range of factors, such as the lack of a diverse mental health care workforce, the absence of culturally informed treatment options, and stereotypes and discrimination associated with poor mental health.

Across racial and ethnic groups, about one in five adults say there was a time in the past three years when they thought they might need mental health services or medication but did not receive them. This share rises to about half (48%) among those with self-reported fair or poor mental health status, with about four in ten or more White (53%), Black (47%), and Hispanic (39%) adults who report fair or poor mental health saying they went without mental health services or medication that they thought they needed in the past three years (Figure 3).

Adults who report unfair treatment by or negative experiences with a health care provider are more likely to say they went without needed mental health care. As previously reported, Black, Hispanic, AIAN, and Asian adults report higher levels of unfair treatment when seeking health care than their White counterparts. Adults who say they were treated unfairly or with disrespect by a health care provider are more likely to report not getting mental health services they thought they needed compared to those who do not report unfair treatment (41% vs. 18%) (Figure 4), and this difference persists among those with self-reported fair or poor mental health status (67% vs. 40%). Similarly, adults who say they’ve had at least one negative experience with a health care provider, such as 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 are more likely to report not getting mental health services they thought they needed compared to adults who did not report a negative experience (35%. vs 15%). This difference also persists among those with self-reported fair or poor mental health status (56% vs. 37%).

Among adults who say they needed but went without mental health services, about half (48%) say they tried to find a mental health care provider, while the remaining half (52%) say they did not. Additionally, seven in ten parents with children who they thought might need mental health services or medication but went without them in the past three years (or 14% of all parents) say they tried to find a provider for their child.

Adults who received or tried to find a mental health care provider for themselves or their children identified scheduling delays, difficulty finding a provider who could understand their background and experiences, and concerns about affordability or coverage as challenges. Overall, 32% of adults received mental health services or tried to find a mental health care provider for themselves or their children in the past three years. Among these adults, about four in ten say that it was very or somewhat difficult to find a mental health care provider who could treat them in a timely manner (44%), understand and relate to their background and experiences (41%), or who they could afford (41%), and 36% say it was very or somewhat difficult to find one who would take their insurance. Compared to their White counterparts (38%), Asian (55%), and Black (46%) adults are more likely to report difficulty finding a provider who could understand their background and experiences (Figure 5).

Concerns about costs and scheduling difficulties are primary reasons cited for not trying to find a mental health care provider among those who say they needed mental health care. A total of 12% of adults thought they or their children needed mental health services in the past three years but report they did not try to find a provider. Among these adults, the main reasons they say they did not try to find a provider were because they thought it would be too expensive (37%), they were too busy or could not take the time off (31%), or they didn’t think it would help (29%). Somewhat smaller shares say they were afraid or embarrassed to seek care (21%), did not know how to find a provider (15%), or did not think they could find a provider with a shared background or experiences (14%) (Figure 6). Hispanic adults who thought they or their children needed mental health services but did not try to find a provider are more likely than their White peers to say the main reason was because they didn’t know how to find a provider (24% vs. 11%) or that they were afraid or embarrassed to seek care (30% vs. 18%). Black adults who thought they or their children needed mental health services but did not try to find a provider are more likely than their White peers to say the main reason was because they didn’t think they would find one who shared their background and experiences (21% vs. 10%).

Mental Health Crises and Awareness of 9-8-8 Mental Health Hotline

Since the launch of the federally mandated crisis number, 9-8-8, awareness remains low overall, particularly among Black, Hispanic, and Asian adults. In July 2022, 9-8-8 became available to all landline and cell phone users, providing a single three-digit number to access a network of over 200 local and state funded crisis centers where those in need may receive crisis counseling, resources and referrals. While national answer rates increased alongside increases in call volume after the implementation of 9-8-8, awareness of the hotline remains low overall. As of Summer 2023, about one in five (18%) adults say they have heard a lot or some about 9-8-8, with Black (16%), Hispanic (11%), and Asian (13%) adults less likely to say they have heard about 9-8-8 than White adults (21%) (Figure 7). Immigrant adults and adults with limited English proficiency also are less likely to say they have heard about 9-8-8 compared to those who are U.S.-born and English proficient.

Low awareness of the 9-8-8 hotline comes at a time when about one in five adults (21%) say they or a family member ever experienced a severe mental health crisis that resulted in serious consequences such as homelessness, hospitalization, incarceration, self-harm, or suicide (Figure 8). White adults (24%) are more likely to report having had or having a family member who has had a severe mental health crisis compared to Asian (9%), Hispanic (16%), and Black adults (18%), a difference that is largely driven by higher rates among White adults who are younger and have lower incomes. Younger adults (ages 18-29) are more likely to say they or a family member who experienced a severe mental crisis resulted in one of these consequences across racial and ethnic groups, with this share rising to about four in ten young White adults (39%). Similarly, among lower income adults ($40,000 annually or less), about a third (34%) of White adults report this experience compared with lower shares of Hispanic (18%), Black (19%), and Asian (11%) adults.

988, the federally-mandated suicide and crisis line, supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), includes specific services to meet the needs of LGBTQ youth and young adults. Given that LGBTQ people face substantial experiences of stigma and discrimination, more pervasive mental health challenges, and greater unmet need for mental health services, a dedicated 988 service provides a targeted intervention for this community.

LGBT adults are more likely than non-LGBT adults to describe their mental health and emotional well-being as either “fair” or “poor” (39% v. 16%) and more likely to report being always or often anxious, depressed, or lonely over the past 12 months. Especially concerning is that, in 2021, 45% of LGBTQ high school students reported having seriously considered suicide during the past year. However, despite greater need, LGBT people are more likely to report going without a needed mental health services than non-LGBT people. Further, about two-thirds (65%) of LGBT adults say they have experienced at least one form of discrimination in their daily life at least a few times in the past year compared 40% of non-LGBT adults and experiences of stigma and discrimination contribute to mental health challenges. In addition, it has been well documented that anti-LGBTQ policy environments can negatively impact the community’s well-being and debates over LGBTQ rights are currently playing out in the courts as well as on the political stage.

This analysis examines performance metrics to assess utilization of 988’s LGBTQ service (which SAMHSA refers to as the LGBTQI+ subnetwork), compared to 988’s general service usage, from December 2023 to March 2024 (the most current and comprehensive data available). The LGBTQ pilot first launched in September 2022, but LGBTQ specific metrics did not become available to the public until December 2023.

Key takeaways include:

• During the four-month period, 10% of all 988 contacts, including 19% of all texts, were made via 988’s LGBTQ service. Users can contact 988 via call, chat, or text.
• A plurality of contacts to 988 came via calls for both the LGBTQ service and the general 988 service, but those using the LGBTQ service were about twice as likely to use text.
• Those using the LGBTQ service were more likely to encounter certain challenges with the service compared to those using the general 988 service. These include double the call abandonment rate (21% v. 11%) and substantially longer call wait times (with monthly averages about double that of the general line).

What is the LGBTQ 988 service and how does it work?

A pilot for a 988 service to address the specific needs of LGBTQ young people was launched shortly after the main 988 line and later expanded to a full-time service. Recognizing the growing need for mental health crisis services in the U.S., the federal government made the mandated Suicide & Crisis Lifeline 988, supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), available to all landline and cell phone users in July 2022, providing for the first time, a single three-digit number to access a network of over 200 local and state-funded crisis centers. In addition, in September 2022, 988 launched a pilot to specially address the needs of LGBTQ young people (those under 25) by offering text, phone and chat services “with a counselor trained explicitly to support LGBTQ+ youth and young adults,” but the service had limited hours. In March 2023, that pilot was expanded to run 24/7 across all modalities. (KFF provided additional history of the 988 line in an earlier brief.)

Operation of the LGBTQ line differs from the main 988 line in that services are provided through specific centers with specialty LGBTQ training rather than local crisis centers located across the country. Originally, the pilot started with one contractor (Trevor Project), but has since evolved to include seven centers (prior to the expansion, there were media reports of capacity issues and other challenges). When contacts cannot be answered by LGBTQ specific operators, they are diverted to the main 988 lines, though data on how often this occurs are not available.

What do we know about awareness and utilization of the LGBTQ 988 service?

As a relatively new service, lack of awareness of the availability of the 988 hotline may be a barrier. Recent survey data from KFF indicate that most (8 in 10) LGBT adults have heard little to nothing about the resource, similar to the share among non-LGBT adults. This low awareness is similar among young LGBTQ adults (18-29), with about 8 in 10 (78%) reporting limited or no knowledge of the 988 hotline, despite there being a service focused on supporting LGBTQ individuals under 25.

Additionally, LGBT adults report more difficulty with the standard police response to a mental health crisis call. LGBT adults are more likely than non-LGBT adults (54% v 26%) to think that that calling 911 in a mental health crisis would do more to hurt the situation than help. Given this backdrop, access to culturally competent mental health services for LGBTQ people may be particularly impactful and targeted efforts may help to increase awareness and use.

Over a recent four-month period, 10% of all 988 contacts, including 19% of texts, were made via 988’s LGBTQ service (Figure 2). This is higher than the distribution of LGBT people in the population as a whole (7%). Since younger people are more likely to identify as LGBTQ, including 20% of Generation-Z, it could help to explain the relatively high rates of LGBTQ service use, especially given the service’s focus on younger people. Greater prevalence of mental health conditions and experiences of stigma and discrimination among LGBTQ people, may also, help explain high use of the 988’s specialty service.

Traffic to the LGBTQ service averaged 46,998 contacts per month over the period and increased from 45,703 contacts in December 2023 to 51,535 contacts in March 2024 (13%). Traffic increased for the service overall as well, albeit at a slightly slower pace (an 8% increase). Across the four-month period,187,991 individual contacts were made to 988’s LGBTQ service via calls, chat, and text. 1.8 million general service contacts were made to 988.

A plurality of contacts to 988 came via calls, for both the LGBTQ and the 988 service overall, but those using the LGBTQ service were about twice as likely to use text and less likely to use calls (Figure 3). Nearly one-third (31%) of LGBTQ service users contacted 988 via text, compared to fewer than one-in-five service users overall (17%). While it was the most common contact modality for both groups, LGBTQ users were less likely to connect to 988 via call (58% v 70%) than general service users. The use of chat was similar for both groups (11% v 12%). In addition to promoting the service overall to improve awareness, given LGBTQ youth and young adult’s wider preference for text, promoting this modality, along with the call line, may be especially useful in servicing the needs of this population.

Callers to the LGBTQ phone line, however, faced higher call abandonment rates than callers to non-LGBTQ lines (Figure 4). The average abandonment rates for LGBTQ line callers were nearly double the rate of general line callers (21% v. 11%) (Figure 4). SAMHSA uses the term “abandoned” to describe when the person seeking 988 services hears/sees the initial 988 greeting, but is disconnected before engaging with a counselor. Per SAMHSA, this may occur due a technical reason (e.g. internet or mobile connection strength or service interruptions, etc.) or because the person seeking assistance ends the contact before a counselor answer which could also happen for a range of reasons, such as they had to wait too long or decided they were not comfortable discussing their experience. Since LGBTQ people in a mental health crisis may also fear discussing their sexual orientation or gender identity, they may be quicker to change their minds about seeking help and a prompt pick-up may improve call completion. Regardless of the reason for call abandonment, there may be opportunities to improve call experiences for users of the LGTBQ line which are nearly double the wait time of general 988 line. LGBTQ service users had lower abandonment rates for chat and the same abandonment rates for text compared to general line users.

In addition, wait time for the LGBTQ phone line was substantially longer than for 988 calls overall—with monthly averages about double that for the general line (Table 1)—which may contribute to the higher abandonment rates. The average monthly wait time for calls to the LGBTQ line were close to a minute whereas they were about 30 seconds for the general 988 service. In contrast, for other contact methods, average text and chat, wait times were shorter for LGBTQ users compared to general 988 users. While, higher than general line users, the wait times for LGBTQ callers face today may actually represent an improvement from the initial launch period of the service when media reports suggested significant challenges with wait times.

Introduction

The Supreme Court’s Dobbs ruling has heightened interest in affirming the right to contraception. While the Court’s majority opinion stated that the Dobbs decision does not “cast doubt on precedents that do not concern abortion,” Justice Thomas argued in his concurring opinion that in future cases, the Court should reconsider precedent that relied on the same principles as Roe – including Griswold v. Connecticut, the Court’s 1965 landmark decision that recognized the right of married people to obtain contraceptives – and overturn those decisions. The prospect of the Court overturning Griswold moved some in Congress to introduce federal legislation that would protect the right to contraception, though that legislation is unlikely to advance in the current divided Congress. Similarly, some state legislators have recently introduced measures to protect the right to obtain contraceptives.

However, even with the current constitutional protections of Griswold in place, uncertainty has emerged around people’s ability to access certain contraceptive methods, such as IUDs and emergency contraceptive pills (often confused with medication abortion), which are erroneously believed by many to be abortifacients. If, as the Supreme Court’s majority indicated, the basis for their reasoning hinges on whether “potential life” is involved in a law, the conflation of contraception with abortifacients could be the reasoning in a future case or in the application of certain laws. Since the Dobbs decision in 2022, a growing number of states have passed laws or constitutional amendments to secure the right to contraception for their residents. Recently, former president Donald Trump said that he believes the right to contraception should be up to the states, a statement he followed up with a social media posting saying that he would not limit contraception. With several state ballot initiatives on the path to be facing the voters November 2024 and the former president’s statement on contraception, this issue is likely to emerge as an election issue this fall. Senate Majority Leader Schumer also recently stated his intention to take a vote to the Senate floor on a bill that would protect contraceptive access nationally. This issue brief explains how misinformation about contraceptives and how pregnancy is defined in state abortion bans may impact contraceptive access, and outlines the legal protections some states have established to affirm the right to obtain contraceptives.

Background

Supreme Court Decisions Recognizing the Right to Contraception

Currently, the right to contraception is protected by two landmark Supreme Court decisions, Griswold v. Connecticut (1965) and Eisenstadt v. Baird (1972). In Griswold, the Court recognized that the constitutional right to privacy encompasses the right of married people to obtain contraceptives. Prior to the Griswold decision, many states outlawed contraceptives, prohibiting clinicians from prescribing, or even discussing, contraceptive methods with their patients. After the Griswold decision, some states continued to have these prohibitions for single people, only allowing married women to obtain contraceptives. These laws spurred the litigation that resulted in the High Court’s decision in Eisenstadt, where the Court extended the constitutional protections of Griswold to unmarried people.

Misconceptions about Emergency Contraceptives (EC) and IUDs

Although intrauterine devices (IUDs) and emergency contraceptives (EC) – such as Plan B, Ella, and the emergency application of IUDs – work by preventing pregnancy, many people mistakenly believe they are abortifacients and can end a pregnancy. Polls indicate that as many as 73% of people incorrectly think emergency contraceptive pills can end a pregnancy in its early stages. Additionally, some people wrongly believe that IUDs work primarily by preventing implantation of a fertilized egg on the uterine lining.  However, research has shown that these contraceptive methods work by inhibiting ovulation or by making it harder for sperm to reach an egg. Despite some common misconceptions, emergency contraceptive methods and regular use of the IUD do not terminate a pregnancy, stop the implantation of a fertilized egg, or affect a developing embryo.

Some Abortion Bans May be Interpreted to Limit Contraceptive Access

The definitions that abortion bans in some states employ, coupled with the misunderstanding that certain contraceptives are abortifacients, may be used to limit access to contraceptives. While leading medical organizations define pregnancy to begin at the implantation of a fertilized egg, a number of abortion bans define pregnancy to begin at fertilization and “fetus” and “unborn children” as living humans from fertilization until birth. The total abortion ban in Tennessee, for instance, defines pregnancy as the “reproductive condition of having a living unborn child within [the pregnant person’s] body throughout the entire embryonic and fetal stages of the unborn child from fertilization until birth.” If abortion bans establish that a pregnancy exists from the moment of fertilization, preventing the implantation of a fertilized egg could be construed as terminating a pregnancy. This kind of definition could potentially be used to ban or restrict contraceptive methods that people incorrectly believe to end a pregnancy.

For example, Missouri defines abortion to outlaw “[the] termination of the pregnancy of a mother by using or prescribing any instrument, device, medicine, drug, or other means or substance with an intention other than to increase the probability of a live birth or to remove a dead unborn child”. The ban additionally defines “unborn child” as “the offspring of human beings from the moment of conception” — which they define as fertilization — “until birth.”  The ban does not provide a definition for pregnancy, but instead establishes personhood for fertilized eggs, which could be interpreted as banning anything that prevents the implantation of a fertilized egg on the uterine lining, a possibility the state’s governor did not firmly deny in the immediate aftermath of the Dobbs decision. As a result, when the state’s abortion ban went into effect, a major hospital system in Missouri immediately stopped providing Plan B – an emergency contraceptive – out of fear of charges that could have resulted from a prosecutor’s misunderstanding of how Plan B works. The hospital system resumed providing the emergency contraceptive after the Attorney General’s office and the governor clarified that the ban did not affect Plan B. However, this situation demonstrates how the definitions included in abortion bans, which imply pregnancy starts at fertilization, coupled with misunderstandings of how contraceptives work, could limit access to the full range of contraceptive methods.

Currently, most other abortion bans that define pregnancy to begin at fertilization also limit the definition of abortion to providing procedures or medication to people “known to be pregnant” or with “clinically diagnosable pregnancies”. This definition of abortion would preclude these bans from being used to limit contraceptives. This is because contraceptives – emergency or otherwise – do not end an existing pregnancy and emergency contraceptives are only effective up to 5 days after intercourse, while the earliest a pregnancy can be clinically confirmed is approximately 10 to 11 days after fertilization. Even with a misunderstanding of how contraceptives work, these bans do not affect conduct prior to the time when a pregnancy can be confirmed. Additionally, the abortion bans in a few states explicitly clarify that they do not prevent the prescription, sale, or transfer of birth control devices and oral contraceptives.

Notably this issue came up in the 2023 race for Kentucky Governor. In a questionnaire from a state anti-abortion organization, one Republican contender indicated his support for fetal personhood, and prohibiting public funds for abortion with a definition that included contraceptive methods such as the “morning after pill,” Norplant, Depo Provera and the so-called “standard birth control pill.”  While the definition was provided by the anti-abortion organization, not the candidate, it illustrates the lack of understanding of contraceptive mechanisms of action and fails to distinguish between a drug or device that prevents pregnancy and those that are used to terminate a pregnancy.

State Protections for the Right to Contraception

Fourteen states – California, Colorado, Florida, Illinois, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, Ohio, Oregon, Rhode Island, Vermont, and Washington – and D.C. currently have legal or constitutional protections for the right to contraception. In six states and D.C., these protections were enacted since the Supreme Court’s decision in Dobbs in June 2022 as a legislative and citizen response to the fall of Roe.  In California, Michigan, and Vermont, voters passed constitutional amendments through ballot measures in the November 2022 election recognizing a broad right to reproductive autonomy, which includes the right to use or refuse contraceptives. In these states, the right to reproductive autonomy also includes the right to abortion and sterilization. In addition to the three states that had constitutional amendments in the November 2022 ballot, the legislatures in D.C., Minnesota, and New Mexico have enacted laws protecting contraception since June 2022. And in 2023, Ohio voters approved Proposition 1, amending their state constitution to protect reproductive decisions, including those regarding contraception and abortion.

Although a number of the protections for contraception were enacted post-Dobbs, more than half of the states that have such protections instituted them before June 2022. Most of these laws – including those in Colorado, Illinois, Massachusetts, New Jersey, Rhode Island, and Vermont – were passed in the years leading up to the fall of Roe. Of the states that currently protect the right to contraception, all but three enacted these protections after 2019. The states of Oregon, Washington, and Florida had enacted their laws protecting contraceptives in 2007, 1991, and 1972, respectively.

Most laws protecting the right to contraception also protect a broader set of reproductive health care decisions, such as miscarriage management, maternity care, and assisted reproduction. Some states, such as Florida and Oregon, however, have more specific laws protecting the right to contraception. Oregon has separate protections for emergency contraception, voluntary sterilization, and termination of pregnancy. In fact, Florida is the only state with a statutory right to contraception that also has passed abortion bans, with a 6-week LMP ban in effect.

Much like any other legal protection, enshrining these rights in the state constitution creates stronger and more stable protection than simply enacting laws, which can be repealed with a change in party control of the state legislature or Governor. In contrast, a constitutional amendment that explicitly protects the right to contraception, or reproductive autonomy more broadly, is harder to change or repeal.

Proposed State Bills and Constitutional Amendments

Legislators in several states have introduced bills and proposed constitutional amendment ballot measures to protect the right to contraception since the Dobbs decision. Legislators in Hawai’i, Maryland, Nevada, and Washington, among other states, have proposed constitutional amendments to create protections for contraception. Most of these measures are in committee or awaiting a vote with the legislature, but the Maryland and Nevada measures have passed. Maryland’s proposed constitutional amendment will be on the November 2024 ballot. In Nevada, constitutional measures must pass twice in the legislature before they are placed on a ballot and the earliest it may be listed on the ballot is November 2026. Further, lawmakers in several states, including Arizona, Iowa, and Virginia, have introduced bills protecting the right to contraception during the 2023 and 2024 legislative session. None of these bills passed during the 2023 legislative session. The Virginia bill introduced during the 2024 session has passed both chambers, but it was vetoed by the governor.

Federal Response

At the federal level, the Right to Contraception Act – a bill that would have protected the right to obtain and use contraceptives – and the Access to Safe Contraception Act – which would prevent states from banning the prescription, provision, or use of FDA-approved contraceptives – were introduced in the House and the Senate in the weeks after the Supreme Court issued the Dobbs decision. Shortly after the bill was introduced, the then Democrat-led House passed the Right to Contraception Act, but it did not receive a vote in the Senate due to a lack of the necessary votes needed to end a filibuster. The Right to Contraception Act was reintroduced in the current Congressional session in June 2023, but it does not have sufficient support to pass in the House or end the filibuster in the Senate at this time. Senate Majority Leader Charles Schumer has announced his intention to fast-track a Senate floor vote that would codify the right to contraception that was granted in the Griswold case assuring that this will be raised by Democrats as an election issue.

In the months following the Dobbs decision, President Biden issued two executive orders aiming to protect access to reproductive health care services, including contraceptives.  While the executive orders do not specifically address the “right” to contraception, they call on federal agencies and regulators to assure that access to contraceptive services and supplies is broad and unimpeded by barriers related to costs, coverage, availability, and other factors. For example, in July 2022, under the directive of one of these executive orders, the U.S. Department of Health and Human Services issued guidance reminding retail pharmacies of their obligations under federal civil rights law. Specifically, the guidance pointed out that “if [a] pharmacy otherwise provides contraceptives (e.g., external and internal condoms) but refuses to fill a certain type of contraceptive because it may prevent pregnancy, the pharmacy may be discriminating on the basis of sex.”

Recent KFF polling suggests that 21% of adults consider the right to contraception to be a threatened right, rising to over one-third of Democrats. One in four Democratic women feel that the right to contraception is under threat, but concern is lower among Republican women (8%). Notably, many are not sure whether it is a secure right, but that may change as the issue gets additional attention in the upcoming election.

In 45 states, fewer than half of nursing facilities currently meet all three staffing minimums required in the final federal rule that the Centers for Medicare and Medicaid Services (CMS) released in April, and in 28 states, less than a quarter do, according to a new KFF analysis. The share of facilities that meet these requirements ranges from 5% or lower in four states (AR, TN, TX and LA) to 50% or higher in five states (AK, ND, ME, HI and OR) and DC.In rural areas, 20% of nursing facilities currently meet these standards, compared to 18% in urban areas. Despite having similar starting points, nursing facilities in urban areas have two fewer years to comply with all provisions of the rule, facing a deadline of May 2027 compared to May 2029 in rural areas. Though they face different challenges, urban and rural facilities currently have similar staffing patterns and both face potential staffing shortages. Rural facilities may struggle to find staff because there are fewer available workers, while urban facilities may struggle because available workers have more job options.  

Across the U.S., only 1 in 5 (19%) nursing facilities currently meet all three staffing minimums. The share that comply is even lower among for-profit facilities (only 11%), compared to 41% of non-profit facilities and 39% of government facilities. When the new federal requirements are fully implemented, nursing facilities will be required to maintain at least 0.55 registered nurse and 2.45 nurse aide hours per resident day (HPRD) in addition to the overall 3.48 HPRD requirement. Nursing facilities may apply for exemptions from these minimum staffing requirements if they are located in an area with workforce shortages. The nursing home industry has identified the cost of hiring and retaining sufficient staff as a major concern, while resident and family advocates have long said new requirements are necessary to address well-documented issues with the quality of patient care.

Forthcoming decisions about how CMS will enforce the new staffing requirements and the ease by which facilities can acquire hardship exemptions may impact the effectiveness of the federal rule as well as how much costs could rise.