Medicare is the federal health insurance program that covers over 65 million adults 65 and older and younger adults with long-term disabilities. Medicare is a very popular program, with 81% of the public holding favorable views of the program, and is viewed positively by large majorities of Democrats, Republicans, and Independents.

Over the past 15 years, the role of private plans in Medicare has increased dramatically. Today, more than half of all Medicare beneficiaries are enrolled in a Medicare Advantage plan, with an average of 43 plans to choose from in addition to traditional Medicare. Beneficiaries in traditional Medicare can choose among 24 stand-alone Part D plans, on average, and may choose supplemental coverage, such as Medigap, if they don’t have supplemental coverage under Medicaid or an employer or union-sponsored retiree health plan. This increasingly crowded marketplace has been accompanied by extensive marketing and advertising as well as agents and brokers competing to attract enrollees.

To capture Medicare beneficiaries’ views and experiences in choosing between traditional Medicare and private plans, and among private plans, and the factors that influence these decisions, KFF worked with PerryUndem to conduct focus groups with Medicare beneficiaries in the Fall of 2022, during the annual Medicare open enrollment period. This report summarizes first-hand accounts of participants’ reactions to phone calls, TV advertisements and other marketing activities they encounter during the open enrollment period, what influences their decision-making, including the role of licensed agents (also known as brokers), how much Medicare beneficiaries understand about their Medicare choices, what they think of the Medicare marketplace, and how well their Medicare coverage is working for them.

The focus group participants included Medicare beneficiaries ages 65 and older and younger adults with disabilities who make health coverage decisions for themselves and/or their spouse or family member. Some focus groups also consisted of people with both Medicare and Medicaid (also referred to as dual-eligible individuals or dual eligibles) as well as adults 64 years old who were approaching Medicare enrollment. Because the study focused on decisions pertaining to Medicare coverage, including Medicare Advantage and traditional Medicare supplemented by Medigap, we excluded people on Medicare with retiree coverage from a former employer or union.

Key Takeaways

• Many participants reported experiencing aggressive marketing tactics pushing Medicare plans, including unsolicited phone calls. Many participants reported getting frequent phone calls from brokers or plan representatives advertising Medicare plans, though it was not always clear to participants who was calling.
• Nearly all participants have seen TV advertisements that are marketing Medicare, most frequently Medicare Advantage plans. Participants reported they were often confused about who was sponsoring the ads. Some participants emphasized that who was sponsoring the ads was often unclear, noting many of the ads had the appearance of being sponsored by the government though they believed the ads were in fact sponsored by private companies.
• Participants did not trust the content of the ads, particularly the ones that marketed a slew of “free” benefits. In general, many thought TV advertisements were misleading. Celebrities are often spokespeople for these advertisements, though participants did not seem to be swayed by them. Overall, participants said that Medicare private plan marketing and advertising did not play a role in their plan choices.
• Most participants found the process of selecting their coverage to be confusing, difficult and overwhelming. As a result, many participants relied on a broker to assist them when choosing their coverage and valued their expertise. Participants who use brokers to help select and enroll in a Medicare plan say brokers are a trusted resource. Most of the participants who used brokers did not seem bothered by potential financial incentives to enroll them in a certain plan.
• Few participants used government resources when making coverage decisions, such as the Medicare Handbook or 1-800 Medicare, but those participants who did use these government resources generally found them helpful. Most participants had not heard of or used State Health Insurance Assistance Programs (SHIPs), which provide local and objective insurance counseling to people on Medicare.
• Focus group participants highlighted a number of factors that were important in choosing their coverage when they first enrolled in Medicare, including premiums and out-of-pocket costs, access to specific doctors, availability of extra benefits, and coverage of prescription drugs. Some participants who are enrolled in Medicare Advantage plans also said they enrolled in a particular plan because its name was familiar or because the company had a good reputation. Participants generally did not take into account Medicare’s star quality ratings of plans to inform their plan choices, though some did their own research on a plan’s quality using non-government resources.
• Most focus group participants – whether in traditional Medicare or Medicare Advantage – said they were relieved to get on Medicare and are satisfied with their coverage. However, some participants cited specific issues with their coverage that varied based on their source of Medicare coverage.
• Participants with traditional Medicare and a supplemental Medigap policy are generally pleased with their coverage, including low or no cost-sharing for Medicare services, protection against catastrophic expenses, broad access to providers since virtually all physicians take Medicare and Medigap, and feeling that have control over their health care, but some expressed concern about the cost of Medigap premiums.
• Participants in Medicare Advantage are also generally satisfied with their coverage because of the zero or low premiums, and extra benefits offered by their plan, such as dental, vision, and hearing services, but some encountered high medical bills when using certain services, faced delays in care, such as having to wait weeks to see specific physicians due to prior authorization and referrals, and had issues in accessing preferred doctors due to network restrictions.
• Dual-eligible participants – whether they had Medicare coverage through traditional Medicare or a Medicare Advantage plan – also reported being generally satisfied with their coverage, particularly due to the low out-of-pocket costs for their health care, such as no copays for doctor’s visits. However, some-dual eligible participants with Medicare Advantage had issues finding providers, such as primary care doctors, who would take both their Medicare and Medicaid coverage.
• Participants enrolled in Medicare Advantage, including some dual-eligible individuals, also noted difficulty using some of their supplemental benefits, particularly dental benefits, due to network restrictions and certain providers not taking their coverage.
• Participants in Medicare Advantage and Medicare Part D stand-alone drug plans reported being frustrated at the high out-of-pocket costs of some of their prescriptions.
• The majority of participants do not review their coverage options every year, and even fewer switched plans because they felt they would not be better off with a different option. Participants generally feel they made the right choice – whether in traditional Medicare or Medicare Advantage – when selecting their coverage and feel it is working well enough for them. Therefore, participants do not see the need to look again at their coverage options; however, many wish they had had more information before enrolling.
• Some participants with both Medicare and Medicaid were concerned about losing their Medicaid coverage, and were anxious about losing Medicaid during the redetermination process as states resume disenrollments after a three year pause during the pandemic.

Introduction

The Medicare plan landscape has transformed markedly in recent years, with more than half of all Medicare beneficiaries enrolled in Medicare Advantage plans. When Medicare beneficiaries first enroll in Medicare and during the annual open enrollment period, they can choose traditional Medicare or enroll in a Medicare Advantage plan. If Medicare beneficiaries select traditional Medicare, they may also need to purchase a stand-alone Part D prescription drug plan (PDP), and potentially a supplemental Medigap plan, which fully or partially covers Part A and Part B cost-sharing requirements. In lieu of traditional Medicare, beneficiaries can get coverage through private Medicare Advantage plans, which are mainly HMOs and PPOs, that provide all Medicare Part A and B benefits, often for no additional premium for plans open for general enrollment (other than the Part B premium), typically include Part D drug coverage, and may cover other benefits such as dental, vision, and hearing. Some people with Medicare may otherwise receive supplemental coverage through an employer retiree health plan or Medicaid, which may supplement either traditional Medicare or a Medicare Advantage plan.

Dozens of private Medicare Advantage and Part D drug plans are available to people on Medicare. With a large number of plans and coverage options to review, beneficiaries have a myriad of choices to make when they enroll in the Medicare program, particularly as there may be tradeoffs for each of these decisions. For example, Medicare Advantage plans typically have lower premiums compared to traditional Medicare plus a Medigap policy and have extra benefits that traditional Medicare does not cover, such as dental, vision, and hearing. However, Medicare Advantage plans have limited provider networks and apply cost management tools such as prior authorization, which traditional Medicare does not.

Both people in Medicare Advantage and traditional Medicare also make choices about their prescription drug coverage, which can vary across numerous domains, including premiums, cost sharing, formularies, and pharmacy networks, among others.

Further, each year, plans may change their premiums, benefits, and other features, and beneficiaries have the opportunity to assess these changes and switch plans during the annual open enrollment period. At the same time, people with Medicare are often inundated with marketing and advertisements for private Medicare plans – typically Medicare Advantage plans – which can add to the complexity of decision-making around Medicare choices.

KFF research has shown, however, that few beneficiaries revisit their coverage decisions each year to determine which option is best for them based on their individual needs and the specific features of the plans available to them, and few change their coverage at all: during the open enrollment period for 2020, 10% of Medicare beneficiaries with Medicare Advantage switched plans. This could be because beneficiaries are satisfied with their current coverage selection, but also may also speak to the challenges of understanding and comparing the multitude of plan options.

To better understand Medicare beneficiaries’ experience with the Medicare program, how they make their Medicare coverage choices, the factors that influence these decisions, including the role of marketing and brokers, and whether they reconsider their plan choices, KFF worked with PerryUndem to conduct a series of focus groups to provide insight on these issues (see Appendix for more details on focus groups).

Perspectives from Beneficiary Focus Groups on Medicare Coverage, Marketing, and Plan Choice

• Focus group participants said they were inundated by Medicare marketing, including unsolicited phone calls and TV ads, and believed the ads were often misleading and deceptive
• Participants found selecting Medicare coverage overwhelming and relied on brokers to assist them with their choices while few used official Medicare resources
• Participants said they considered many factors when selecting Medicare coverage, including premiums, access to doctors, extra benefits, and coverage of prescriptions
• Participants reported high satisfaction with Medicare coverage but cited specific issues that varied depending on their source of Medicare coverage
• Despite high satisfaction, participants cited specific Issues that varied depending on their source of Medicare coverage
• Participants generally feel they made the right choice when selecting a plan, and most participants have not revisited their plan choices

Experiences Unique to Dual-Eligible Participants

• Dual-eligible participants had varying experiences signing up for Medicaid coverage with some participants choosing coverage and others being assigned their coverage
• Some dual-eligible participants were concerned about the possibility of losing medicaid coverage due to the annual redetermination process

Focus Group Participants Said They Were Inundated by Medicare Marketing, Including Unsolicited Phone Calls and TV Ads, And Believed the Ads were Often Misleading and Deceptive

Private Medicare plans are allowed to engage in a variety of Medicare marketing and communication activities, including over the phone, on television, and in-person, as long as they adhere to the Centers for Medicare & Medicaid Services (CMS) rules and regulations. However, there has been concern over misleading and deceptive marketing tactics by private Medicare plans as well as third-party marketing organizations who work for these plans. For example, CMS has seen a substantial increase in beneficiary complaints in recent years – they received more than twice as many beneficiary complaints related to marketing in 2021 (~40,000) compared to 2020 (~16,000). In response to these and other concerns, CMS finalized new marketing regulations in May 2022 and in April 2023 to help protect Medicare beneficiaries who are looking for Medicare coverage.

Focus group participants were asked to provide their reactions to Medicare marketing and advertising, including over the phone and on television, whether they could tell who was sponsoring these calls or ads, what they thought about the messaging, how they felt about celebrity spokespeople in many of the ads, and if any of these communications played a role in their Medicare choices. Dual-eligible participants had similar reactions to those enrolled only in Medicare.

Unsolicited phone calls

Many participants reported getting frequent unsolicited phone calls advertising Medicare plans. Participants said marketers promoting these plans used deceitful tactics, and participants usually ignored these calls.

For marketing solicitations over the phone, private Medicare plans are subject to a number of requirements and are not permitted to use telephone solicitation (that is, cold calling), as well as robocalls, text messages, or voicemail messages if unsolicited. However, a recent report from the majority staff of the Senate Finance Committee documented robocalls, telemarketing, and frequent phone calls as a common source of complaints among Medicare beneficiaries. Most focus group participants mentioned receiving unsolicited phone calls from marketers, some of whom were calling from insurance plans or were brokers or agents representing these plans, but many participants said it was not always clear who was calling.

Confusion about TV ad sponsors

Nearly all participants have seen TV advertisements that are marketing Medicare, most frequently Medicare Advantage plans. However, many participants emphasized they were often confused who was sponsoring the ads and that many ads had the appearance of being sponsored by the government though they believed the ads were in fact sponsored by private companies.

One area of particular concern to CMS has been the use of the Medicare name and logo to give the appearance that advertisements or communications are being sponsored or endorsed by the Medicare program or the federal government, when they are actually sponsored by private Medicare plans or by representatives acting on behalf of these plans. The recent Senate Finance Committee majority staff report has also documented similar beneficiary complaints that highlight confusion over what is truly official correspondence and advertisements from the government. Likewise, a KFF analysis of Medicare TV advertising found that more than one in four ads aimed at the most recent open enrollment period, in the fall of 2022, included a government-issued Medicare card or an image that closely resembled it.

In order to address this issue, CMS has finalized changes to this type of marketing, which would prohibit the use of the Medicare name, CMS logo, or official products, including the Medicare card, in a misleading manner. Similar to these complaints, focus group participants also expressed confusion over who was sponsoring some of the ads. Many participants noted that the ads were clearly designed to give the impression they were coming from the government when they believe these ads were fact sponsored by private companies.

“Free” is not always free

One of the most common complaints among participants about TV marketing is that they often advertise that services and benefits are “free”, though this is not always true.

In many of the focus groups, participants mentioned their Medicare Advantage plans come with zero premiums and copays and access to many extra benefits, some of which give them additional money to spend, such as money for over-the-counter items. A KFF analysis of Medicare TV advertising aimed at the most recent open enrollment period, in the fall of 2022, confirmed that messaging about extra benefits was included in more than 90% of ads, while messaging about the potential for lower out-of-pocket costs was present in 85% of Medicare ads. Despite the fact that some beneficiaries report receiving these types of benefits at no cost, nearly all participants, regardless of the Medicare coverage they have, do not trust the content of these type of ads and are inclined to ignore it.

Participants feel inundated by TV ads

In general, participants feel inundated by TV ads. Most find them off-putting, misleading, and unhelpful, and say the ads did not influence their Medicare plan selections.

Celebrity spokespeople

While celebrities are often spokespeople for Medicare Advantage plans, participants did not seem swayed by them and frequently disregarded them.

KFF analysis has found that celebrity endorsements are commonly featured in TV ads for Medicare Advantage, appearing most often in ads sponsored by brokers and other third-party organizations, such as marketing firms, who may contract with insurers to promote plans and boost enrollment. Participants reported encountering these ads but most did not find the endorsements helpful or persuasive.

Participants Found Selecting Medicare Coverage Overwhelming and Relied on Brokers to Assist Them with Their Choices While Few Used Official Medicare Resources

The average Medicare beneficiary has an average of 43 Medicare Advantage plans to choose from and 24-stand-alone prescription drug plans to choose from. Most participants said they were surprised to hear that was the average number of coverage options available and were overwhelmed at the idea of having to sort through so many plan options.

Many find the process overwhelming

Most participants said the process for selecting a plan was overwhelming and confusing to navigate. Some did try to sort through plan options themselves, but emphasized the process was challenging.

Use of Medicare insurance brokers

For this reason, many participants have used a broker at some stage to assist them when choosing their plan, and many found them helpful in sorting through the enrollment process. Many brokers were recommended by a friend or family members. For people who use brokers, they are seen as a trusted resource.

Many participants, including some dual-eligible individuals, relied on brokers to help narrow down their plan options. Medicare insurers contract with brokers to solicit and enroll beneficiaries in their plans, and in return, the brokers receive a commission from the insurer. Research has shown that people who received help making decisions about their Medicare coverage most commonly turned to brokers to help them compare and narrow down their Medicare plan options, and the focus group participants generally confirmed this trend.

Participants who used brokers said they liked that brokers simplify shopping, can ensure they choose a plan with their preferred providers, and can help navigate whether a plan covers their prescriptions. When dual-eligible participants used brokers, it was generally to help them choose a Medicare Advantage plan. In many cases, brokers were recommended to them by family and friends, who reported being happy with their plans, so participants see brokers as a trusted resource.

Beneficiaries not bothered by commissions that brokers received 

Most of the participants who used brokers did not seem bothered by potential biases or financial incentives to enroll them in a Medicare Advantage plan and relied on their advice.

Medicare brokers receive a commission for enrolling beneficiaries in plans, whether they are for Medicare Advantage, stand-alone Part D plans or supplemental Medigap plans. Yet, research has shown that brokers tend to be paid more for enrolling beneficiaries in Medicare Advantage plans rather than Medigap plans, which could create conflicts for brokers who may have an incentive to recommend one type of plan over another based on their potential compensation rather than the needs of the beneficiary. In general, beneficiaries did not seem to be aware how brokers were paid – that they might be paid by a specific insurer or receive different fees for separate products. For example, in 2020, Medicare Advantage commissions were $510 nationally, while commissions were $322 for a Medigap supplement and $78 for a Part D plan, a total commission of $400 for Medigap plus a Part D plan. However, when asked if they had concerns about any potential biases or conflicts of interest, beneficiaries did not seem bothered by the commissions that brokers received as long as they felt they were getting good recommendations on their plan options.

Few have used official Medicare information resources

Few participants have used Medicare’s official information resources such as the 1-800 Medicare toll free number, the Medicare.gov website, and the Medicare & You Handbook that is provided each year to all Medicare beneficiaries, though for the few who did, some found these resources helpful.

Medicare has official information resources beneficiaries can turn to help with their coverage decisions, including the 1-800 Medicare toll free number, the Medicare.gov website, including the Medicare Plan Finder, and the Medicare & You Handbook. KFF research has shown that these resources are not widely used, and focus group participants generally confirmed this. Participants who used these resources, however, said the resources were mostly helpful and felt they could get answers to important questions, although some participants thought the toll-free phone number, in particular, was too slow. Further, most focus group participants had not heard of or used State Health Insurance Assistance Programs (SHIPs), which provide local, in-depth, and objective insurance counseling to people on Medicare.

Participants Said They Considered Many Factors When Selecting Medicare Coverage, Including Premiums, Access to Doctors, Extra Benefits, and Coverage of Prescriptions

When Medicare beneficiaries first enroll in Medicare and select their coverage, they are encouraged to weigh a variety of factors, including premium costs, cost sharing for services, access to specific doctors, availability of extra benefits, coverage of prescription drugs, and quality ratings of plans, among others. Beneficiaries may revisit their choice of plan each year during the annual open enrollment period.

Focus group participants were asked what factors entered into their decision making when choosing a plan, how they viewed the process of selecting a plan, and why they ultimately chose Medicare Advantage or traditional Medicare.

Many confused by coverage options and how Medicare program works

Despite looking forward to going on Medicare, many said they were confused, stressed and overwhelmed by the various coverage options and how the Medicare program works.

Many participants lacked awareness or a good understanding about the different Medicare options available to them. They mentioned confusion with the different parts of Medicare – Parts A, B, C, D – and were unclear what makes them different from each other and which parts are mandatory or optional. They often did not know which parts of Medicare were included as part of a Medicare Advantage plan and if that was the same or different as a Medicare “supplement.”

Zero or low premiums often cited as top reason for selecting a Medicare Advantage plan

For those who chose or were considering Medicare Advantage for their coverage, zero or low premiums was often cited as the top reason for selecting a Medicare Advantage plan, followed closely by low cost-sharing requirements for services.

People on Medicare are often concerned about the cost of health care because most live on fixed incomes with limited savings. When thinking about health care costs, the first thing that often comes to mind is a plan’s monthly premium, because it is monthly expense they will incur regardless of their health needs, and it is relatively easy to compare across plans. Many of the focus groups participants noted that they lived on tight budgets and could not afford to pay for coverage that required higher premiums, which may have led them to believe that Medicare Advantage seemed like a more affordable option than traditional Medicare plus a Medigap supplemental policy with an additional premium. Due to their budgets, they also looked closely at copay amounts, particularly for services that they thought they might use with some frequency.

In-network doctors are top priority

Another factor that weighs heavily in their decision-making when selecting Medicare Advantage is whether their doctors are in the plan’s network.

For people considering Medicare Advantage plans, a top priority is whether their doctors are part of the plan’s network. In many cases, people are concerned about maintaining access to their primary care physician, but depending on their health needs, some are more concerned about having access to particular specialists.

Availability of extra benefits in Medicare Advantage

An additional factor that influenced participants’ decision-making is the availability of extra benefits in Medicare Advantage such as dental and vision.

Medicare Advantage plans are able to offer extra benefits not available not offered by traditional Medicare, such as dental, vision, and hearing, as well as some that provide money to enrollees, such as over-the-counter benefits, and for this reason, many participants were attracted to Medicare Advantage plans.

Reasons for choosing traditional Medicare

Those who ultimately chose or were considering traditional Medicare (and often a Medigap supplement) liked the relatively low cost-sharing requirements, comprehensiveness of their coverage, control over their health care, and ability to see any provider they wanted.

Medigap policies, sold by private insurance companies, are supplements to traditional Medicare and fully or partially cover Part A and Part B cost-sharing requirements, including deductibles, copayments, and coinsurance. Medicare beneficiaries with traditional Medicare, including those with a Medigap policy, can see any provider who accepts Medicare. Medigap insurance provided supplemental coverage to 36% of people in traditional Medicare (roughly 11.5 million beneficiaries) in 2020.

Relationships with insurance providers

Some participants had relationships with insurance providers that they felt comfortable with or liked the reputation of the company.

Medicare star quality ratings

Participants did not generally use Medicare’s star quality ratings when making coverage decisions, though some participants used other non-government sources to get information about plan quality.

On the Medicare plan finder, each Medicare Advantage plan has a star rating to provide beneficiaries with additional information about the quality of plans offered in their area. All plans are rated on a 1 to 5-star scale, with 1 star representing poor performance, 3 stars representing average performance, and 5 stars representing excellent performance. When asked whether these star ratings influenced their decision-making when choosing a plan, the majority of participants said no.

For the few participants who did look at ratings, they reported turning to other non-government sources for reviews on a plan’s quality.

Prescription drug coverage important factor in decision-making

Regardless of whether they selected or were going to select traditional Medicare with a stand-alone Part D plan or a Medicare Advantage plan with drug coverage, ensuring that their prescription drugs were covered was also an important factor in participants’ decision-making.

People with Medicare can get prescription drug coverage by enrolling in a stand-alone plan that provides Part D prescription drug coverage for people with traditional Medicare or by enrolling in a Medicare Advantage plan. Coverage of prescription drugs is based on each plan’s formulary, and depending on a plan’s formulary, beneficiaries can also be subject to prior authorization, step therapy, and quantity limits. Medicare beneficiaries with Part D coverage also face cost-sharing amounts for covered drugs and may pay an annual deductible ($505 in 2023) and depending on the plan, a monthly premium.

Participants Overall Reported High Satisfaction with Their Medicare Coverage

Most participants satisfied with Medicare coverage

Most participants – whether in traditional Medicare or Medicare Advantage – were relieved to be on Medicare and reported being satisfied with their Medicare coverage.

Medicare continues to be a very popular program, with 81% of the public holding very or somewhat favorable views of the program. Most participants mentioned being excited or relieved to go on Medicare, often because of the lower costs compared to their previous insurance coverage or because of the security of having Medicare coverage. When asked on a scale of 1-10 how they would rate their Medicare coverage, with 10 being very satisfied, most participants gave their coverage an 8, 9 or 10, saying it is working well for them.

Varied reasons for satisfaction depending on source of coverage

Participants cited a variety of reasons for their satisfaction, including costs, access to providers, and supplemental benefits, depending on their source of Medicare coverage.

Participants with traditional Medicare and a Medigap policy are generally happy with their coverage because they like the relatively low cost-sharing requirements, not having to deal with bills, protection against catastrophic expenses, ability to see any provider they want, and having control over their health care.

Medicare Advantage plan participants pleased with their coverage

Participants in Medicare Advantage plans are pleased with their coverage and noted that this was due to having zero or low premiums, and coverage of extra benefits, such as dental, vision, hearing, services and over-the-counter debit cards.

Dual-eligible participants also generally satisfied with coverage

Dual-eligible participants – whether they had Medicare coverage through traditional Medicare or a Medicare Advantage plan – are also generally satisfied with their coverage, particularly due to the low cost of their health care.

Dual-eligible individuals feel their health care coverage is affordable and covers most services they need. Most referenced the low out-of-pocket costs for their health care, such as no copays for doctor’s visits and prescriptions, as the primary reasons they were satisfied with their coverage. Some who had their Medicare coverage through a Medicare Advantage plan also were pleased at having coverage of some extra benefits, such as an over-the-counter allowance or money to buy food and produce.

Despite High Satisfaction, Participants Cited Specific Issues that Varied Depending on their Source of Medicare Coverage

Concerns about premiums

While participants with traditional Medicare and a Medigap policy are generally pleased with their coverage and access to physicians, they had concerns about the premium.

While Medigap limits the financial exposure of Medicare beneficiaries for services covered under Parts A and B, Medigap premiums can be costly and can rise with age, depending on the state in which they are regulated. Estimated average monthly premiums for Medigap policies can range from less than $100 per month to over $300 per month depending on the plan.

High medical bills for some participants in Medicare Advantage

While many participants with Medicare Advantage are satisfied with their coverage, some with serious medical conditions encountered high medical bills when using certain services.

Delay in care experienced by some participants in Medicare Advantage

Some participants with Medicare Advantage, including some dual-eligible individuals, experienced delays receiving care due to utilization management tools, such as prior authorization and/or referral requirements.

Medicare Advantage plans can require enrollees to get approval from the plan prior to receiving a service, and if approval is not granted, then the plan generally does not cover the cost of the service. Similarly, Medicare Advantage can impose referral requirements, in which a primary doctor must provide a written letter in order for a patient to see a specialist for services, and if not provided, then the plan generally does not cover the cost. In 2023, virtually all Medicare Advantage enrollees (more than 99%) are in plans that require prior authorization for some services. Health insurers use these utilization management tools to both contain spending and prevent enrollees from receiving unnecessary or low-value services, though there are some concerns these requirements may create barriers and delays to receiving necessary care. Some Medicare Advantage participants experienced delays receiving care, but nearly all ultimately got approval for their prior authorization and/or referral requests.

Issues with provider networks 

While Medicare Advantage enrollees were generally aware of the importance of having their doctors in-network, many participants encountered situations when the doctor they wanted to see for a particular service was not in-network. Issues with provider networks was also a particular challenge for dual-eligible participants with a Medicare Advantage plan who sometimes could not find a provider who accepted both their Medicare and Medicaid coverage.

Unlike traditional Medicare, where Medicare beneficiaries can see any provider who accepts Medicare, beneficiaries enrolled in Medicare Advantage have a network of physicians and hospitals for their care. If providers are not in-network, Medicare Advantage enrollees typically must pay more to see out-of-network providers, or they may be responsible for the entire cost of seeing that provider. When beneficiaries select their Medicare Advantage plan, they are encouraged to check whether their preferred providers are in-network as provider networks vary across plans. However, evidence indicates provider directories might not always be accurate, and it may be difficult for beneficiaries to compare networks and providers across plans as they may be in different formats across insurers. Focus group participants noted situations when they could not see their preferred doctor because they were not in their plan network and were frustrated with having to see a different provider.

In addition, some dual-eligible participants with a Medicare Advantage plan, including participants with a dual-eligible Special Needs Plan (D-SNP), reported issues with doctors accepting their health insurance policy. D-SNPs are a specific type of Medicare Advantage plan designed for this population to better coordinate care, though these plans can also look different across states in terms of their levels of coordination. For example, some D-SNPs offer Medicaid and Medicare benefits through different organizations, while some have plans through the same parent company.

Frustration with using some supplemental benefits

Some Medicare Advantage enrollees also voiced frustration with using some supplemental benefits, particularly dental coverage, because cost sharing was higher than expected and due to network restrictions. Network restrictions for extra benefits were also challenging for dual-eligible participants who had a Medicare Advantage plan.

Many people are attracted to Medicare Advantage plans because they offer extra benefits that traditional Medicare does not offer, such as dental, vision, and hearing coverage. However, some participants raised concerns with the costs of these benefits, challenges using these benefits, or finding a provider who covered these services. Like accessing providers covered by Medicare Advantage plans, many Medicare Advantage plans have networks of providers who cover supplemental benefits, or the enrollee will be required to pay more to see someone out-of-network, such as for dental benefits.

Frustration with high cost of certain medications

Some participants were also frustrated by the high cost of certain medications, particularly for those who need specific drugs to manage chronic conditions.

In recent years, many Medicare beneficiaries have experienced high out-of-pocket costs for their prescription drugs. Changes as part of the Inflation Reduction Act, including a $35 monthly copay on insulin that went into effect in 2023, as well as limits on out-of-pocket prescription drug spending in Part D beginning in 2024, and a $2,000 cap beginning in 2025, will help some Part D enrollees with their prescription drug costs.

Participants Generally Feel They Made the Right Choice When Selecting a Plan, and Most Participants Have Not Revisited Their Plan Choices

The marketplace of Medicare private plans is based on the idea that beneficiaries will compare their plan options to find plans that best meet their individual needs. CMS encourages beneficiaries to compare and review their plan options each year, which could enable them to receive care at a lower cost, ensure their preferred providers are in network, and that the prescription drugs they take are covered. However, KFF analysis has shown that most beneficiaries do not compare their plan options in each year.

Majority feel they made the right choice

The majority of participants in the focus groups confirmed this behavior – they explained that they felt that their coverage was comprehensive and did not need to reevaluate their coverage every year though some wish they had more information before enrolling. Additionally, many participants said they are unlikely to switch plans going forward because selecting a new plan would be too much work, and they did not feel confident they would be better off with another type of coverage. For dual-eligible participants who made a choice about their Medicare coverage, they also generally did not feel the need to switch plans going forward.

But some say they shop around

However, a few of the participants said they do shop around, sometimes every year, to ensure they continue to have the best plan that meets their needs.

Experiences Unique to Dual-Eligible Participants

People with both Medicare and Medicaid, also referred to as dual-eligible individuals or dual eligibles are enrolled in both programs and must meet eligibility requirements for both programs. They receive their primary health insurance coverage through Medicare and some assistance from their state Medicaid program. Together, these two programs help to shield low-income beneficiaries from potentially unaffordable out-of-pocket medical and long-term care costs: Medicaid typically pays the Medicare Part B premium and may also pay for Medicare’s other cost-sharing requirements; Medicaid also helps pay for services that are not covered by Medicare, such as long-term services and supports. While nearly all dually eligible beneficiaries have low incomes and very modest savings, they are otherwise a diverse group in terms of age and physical and mental health.

To capture the unique experiences faced by dual-eligible individuals, we conducted two focus groups that consisted exclusively of these beneficiaries.

Dual-Eligible Participants Had Varying Experiences Signing Up for Medicaid Coverage With Some Participants Choosing Coverage and Others Being Assigned Their Coverage

As mentioned above, people with Medicare have the choice between traditional Medicare or a Medicare Advantage plan, which can include an individual plan open for general enrollment as well as a dual-eligible Special Needs Plan (D-SNP). Dual-eligible individuals who are eligible for full Medicaid may receive those Medicaid benefits through capitated managed care organizations (MCOs) or through fee-for-service (FFS). Options for Medicaid coverage vary depending on the state that the enrollee lives in as do the mechanisms for beneficiary enrollment. Some states provide dual-eligible individuals with the ability to choose their plans, others assign people to a plan, and still others assign enrollees to a plan but offer them the opportunity to disenroll and select a different option.

As a result, participants had varying experiences signing up for Medicaid coverage, often depending on the state they lived in and whether they had enrolled in Medicare or Medicaid first or at the same time.

Making a choice for Medicaid coverage

Some participants had to make a choice for their Medicaid coverage, and many had help from the state choosing their plan.

Some participants did not have a choice

Some participants did not have a choice of their Medicaid coverage, or someone enrolled them in Medicaid coverage – often the state or county chose their Medicaid plan for them.

Some Medicare enrollees did not realize they might also be eligible for Medicaid

Some who were enrolled in Medicare did not realize they might also be eligible for Medicaid, but their state reached out to them to let them know they should apply for Medicaid coverage.

Some Dual-Eligible Participants Were Concerned About the Possibility of Losing Medicaid Coverage Due to the Annual Redetermination Process

Concerns about redetermination process

Because of the importance of the Medicaid program for addressing their health care needs, some dual-eligible participants were concerned about the redetermination process and anxious about the possibility of losing that coverage.

Prior to the COVID-19 pandemic, states were required to renew Medicaid eligibility for dual-eligible individuals at least once per year. Since March 2020, states have provided continuous enrollment in Medicaid in exchange for enhanced federal funding. This continuous enrollment provision and enhanced federal funding were originally in place until the end of the COVID-19 public health emergency (PHE). In December 2022, the Consolidated Appropriations Act, 2023 (CAA) delinked the provision from the PHE and ended continuous enrollment on March 31, 2023. Beginning April 1, 2023, states have restarted disenrollments after conducting a full review of eligibility. As states begin to “unwind” the continuous enrollment provision, many people will likely be found to be no longer eligible for Medicaid. Others could face administrative barriers and lose coverage despite remaining eligible.

Focus group participants generally had not experienced a loss of Medicaid, but some participants mentioned being concerned with losing their Medicaid coverage in the future due to changes in their incomes, assets, or other eligibility requirements. Many were aware of the renewal requirements even though redeterminations had been on hold during the pandemic.

As more people on Medicare are enrolled in Medicare Advantage, CMS, policymakers, researchers, and the public have become more focused on how the program is serving people on Medicare. Participants across the spectrum of coverage noted that they experienced aggressive marketing tactics, including unsolicited phone calls, and felt inundated by Medicare television advertising, often for Medicare Advantage plans, that they believed to be both misleading and unhelpful.

Participants with Medicare found the process of selecting their coverage to be overwhelming and difficult, and often relied on brokers to help them review and understand their coverage options. Few participants used Medicare’s official resources to assist in their decision-making. When choosing their coverage, participants said they valued a variety of factors, including premiums and other costs, access to preferred providers, availability of extra benefits, and coverage of prescription drugs.

Participants in the focus groups – whether in traditional Medicare or Medicare Advantage – emphasized that they are generally satisfied with their Medicare coverage. Participants in Medicare Advantage plans were pleased with their coverage due to the low or no premium costs, as well as the availability of extra benefits, such as dental, vision, hearing, and debit cards. Participants with traditional Medicare and a Medigap policy were happy with their coverage due to the low or no cost-sharing requirements, no network restrictions on seeing their preferred providers, and the ability to control their own health care.

However, some participants, particularly in Medicare Advantage plans, also noted that there are elements of their coverage that caused them frustration, including delays receiving care due to prior authorization and referral requirements as well as facing limitations in seeing their preferred doctors due to limited networks. In recent months, CMS and policymakers have sought to address some of these issues through both legislation and rulemaking, including rules that would streamline the prior authorization process and place additional limitations on Medicare marketing.

Most dual-eligible participants who have both Medicare and Medicaid said they are satisfied with their coverage, whether in Medicare Advantage or traditional Medicare, though some in Medicare Advantage encountered problems finding a provider in their plan’s network. Further, some participants with Medicaid were uniquely concerned about maintaining their Medicaid eligibility and were anxious about losing Medicaid during the annual redetermination process. With Medicaid redeterminations having restarted April 1, states may have begun disenrollments, which could lead to some losing their coverage, though it is unclear how much that would impact focus group participants who generally had not experienced a loss of coverage prior to the pandemic.

In making coverage decisions, participants say they were annoyed by marketing calls and the number of ads marketing Medicare plans on TV, and generally ignored them. Few participants said they intend to review or switch their coverage. While focus group participants were generally satisfied with their Medicare coverage, most were also confused and frustrated by the complexity of the program and lacked confidence in their own ability to compare and choose a source of coverage to best meet their individual needs.

The focus group participants included Medicare beneficiaries ages 65 and older and younger adults with disabilities who make health coverage decisions for themselves and/or their spouse or family member. Some focus groups also consisted of people with both Medicare and Medicaid (also referred to as dual-eligible individuals) as well as adults 64 years old who were not yet enrolled in Medicare. Participants included beneficiaries in traditional Medicare, some with and some without Medigap supplemental coverage, and beneficiaries enrolled in Medicare Advantage plans. Because the study focused on decisions around health plans, we excluded beneficiaries with retiree coverage from a former employer or union.

We conducted 7 focus groups with participants from across the country in November 2022, timed to coincide with the Medicare open enrollment period, which starts October 15 and ends December 7 of each year. Each focus group was conducted virtually by Zoom and included 5-8 participants, differing by age, gender, income, race/ethnicity, health status, and type of insurance coverage. Each focus group lasted one hour and forty-five minutes. Two of the seven focus groups consisted of people with Medicare and Medicaid, with one group consisting of adults 65 and older, and the other group adults younger than 65. One focus group included adults 64 years old who were not yet enrolled in Medicare, but who were starting to think about their Medicare coverage options. One focus group was conducted in Spanish. Individuals who were able to participate in the groups needed to know their Medicare coverage, and if applicable, Medicaid coverage, have two hours of time, a quiet space, a computer, and internet. These characteristics alone may not fully represent many people with Medicare, so the perspectives described in this report may not be generalizable to the entire Medicare population. See Appendix Table 1 for demographic details about the participants.

The analysis includes responses from participants across all 7 focus groups. There are also additional responses from dual-eligible participants that emphasize beneficiary experiences unique to this population.

Opioid use disorder (OUD) is a chronic treatable medical condition affecting birthing parents across all racial and ethnic groups, socioeconomic classes, and geographic locations. Without treatment, opioid use in pregnancy can result in serious negative health outcomes for the fetus and the birthing parent such as increased risk for a stillbirth, pregnancy complications including preterm labor, and death. Medications for OUD (MOUD) – including methadone, buprenorphine, and naltrexone – reduce adverse outcomes for both the birthing parent and child. The American College of Obstetricians and Gynecologists (ACOG) recommends the use of medications, especially opioid agonists (more details below), to manage pregnant women with OUD and advises for continued treatment through the postpartum period. Comprehensive care for pregnant and postpartum women with OUD includes standard prenatal and postpartum care, contraceptive counseling, and the co-prescribing of naloxone and overdose training.

As a major source of coverage for maternity care (covering 42% of all births), and covering an even larger share of women with OUD, and the single largest payer for behavioral health services , Medicaid is particularly well positioned to facilitate access to OUD treatment. Drawing on the 2016-2019 Medicaid claims data from the Transformed Medicaid Statistical Information Systems (T-MSIS), this brief looks at the rates of clinically documented OUD in pregnant and postpartum women as well as the percentage of diagnosed women who receive MOUD treatment. The analysis also explores disparities in clinical diagnosis and treatment based on demographics, such as race/ethnicity and age, along with geographical differences. Differences in clinically documented OUD and treatment rates across various demographics and regions offer insight to help inform ongoing policy conversations aimed at improving access to OUD treatment for pregnant and postpartum parents.

Key Takeaways:

• Analysis of Medicaid claims representing births from 2017 and 2018 in 39 states with usable data shows 2.7% of pregnant or postpartum Medicaid enrollees had clinical documentation of opioid use disorder in their medical claims. This is slightly higher than adults overall (2.0%) and lower than the adolescent and nonelderly adult (12+) Medicaid population clinically diagnosed with OUD (3.3%). There was considerable variation in the rates by states, ranging from a low of 0.4% in Nebraska to a high of 12.4% in Vermont.
• On average, 55% of pregnant and postpartum Medicaid enrollees with documented opioid use disorder received medication as part of their care. Medication treatment rates for pregnant or postpartum Medicaid enrollees with a documented OUD varied substantially with a low of 19% in Kansas to a high of 79% in Maine.
• Younger pregnant or postpartum enrollees had a clinically documented OUD rate (1.6%) that was half of those ages 26 to 34 (3.7%) and 35 years and older (3.1%). Younger enrollees received treatment at somewhat lower rates with 48% getting medication compared to over 55% among those who were aged 26 and older.
• In a subset of 24 states with available data, White pregnant or postpartum Medicaid enrollees had clinically documented OUD rates five times more than Black enrollees (5.5% vs 1.1%, respectively). Clinically documented rates were the lowest among Hispanic enrollees (0.6%). Racial and ethnic disparities persist in the receipt of MOUD. Compared to Hispanic and White enrollees, smaller shares of Black enrollees with a documented OUD received MOUD during the perinatal period (53-57% vs. 31% respectively).
• State laws that take a punitive approach toward substance use during pregnancy may contribute to lower OUD identification and lower treatment rates may be attributable in part to Medicaid utilization controls, prior authorization requirements, and burdensome administrative policies.

How are Medications for Opioid Use Disorder (MOUD) Used to Treat Opioid Used Disorder During the Perinatal Period?

Since the 1970s, ACOG has recommended that MOUD, in combination with behavioral health interventions, serves as the standard treatment for opioid addiction during the perinatal period. MOUD provides stabilization by reducing withdrawal symptoms and the negative health outcomes associated with opioid use. There are several different Food and Drug Administration-approved options for MOUD (Table 1). Methadone and buprenorphine are safe and effective in treating OUD in pregnancy and improve the adherence to standard prenatal care. Naltrexone is another treatment option for OUD, but it is rarely prescribed during pregnancy because there are few studies demonstrating its effectiveness, except in limited circumstances. While behavioral health interventions are encouraged as a supplement to MOUD, we do not discuss them in detail in the current analysis.

Without treatment, opioid use in pregnancy can result in serious negative health outcomes such as fetal distress, intrauterine growth restrictions and ultimately, neonatal abstinence syndrome (NAS) or opioid withdrawal at birth. Pregnant and postpartum parents with untreated OUD are also at increased risk for a stillbirth, pregnancy complications including preterm labor, and death. Notably, opioids played a role in 1 in 10 pregnancy-associated deaths in 2016. Although clinical guidelines recommend the use of MOUD for pregnant and postpartum parents with OUD, most go untreated. Prior studies indicate that only 50-60% of pregnant women in the United States receive any MOUD during pregnancy. In addition to this treatment gap, racial and ethnic disparities have been reported in the receipt of MOUD. Pregnant women of color are less likely to receive any medication to treat OUD.

What are the Rates and Characteristics of Pregnant and Postpartum Enrollees with a Clinically Documented OUD?

Among women with a Medicaid funded live birth in 2017 and 2018, 2.7% or 65,092 enrollees had a clinically documented OUD (Figure 1). This is slightly higher than adults overall (2.0%) and lower than the nonelderly adolescent and adult (12+) Medicaid population (3.3%). For this analysis, any diagnosis or prescription code that suggests the presence of an OUD is defined as a “clinically documented OUD.” Although, other Medicaid studies using claims data show similar rates of maternal OUD, research that adjusts for underreporting finds higher rates. Certain factors may lead to underreporting or reluctance to disclose drug use, which in turn can result in an underestimation of OUD in claims data. Stigma and concerns about legal retribution might make pregnant and postpartum women more careful about disclosing their opioid use to clinicians. Providers may be hesitant to record the diagnosis in the records at all due to concerns about whether documentation could violate the privacy rules in place that provide protection for people receiving any form of SUD treatment. For these reasons, this measure should not be used as a metric to define the overall prevalence of OUD among the pregnant and postpartum Medicaid population because not everyone is screened and diagnoses are not always recorded, but it does provide some insight into how often OUD is recognized and possibly treated in clinical settings.

Rates of clinically documented OUD in pregnant and postpartum Medicaid enrollees vary widely from state to state. For instance, Vermont has the highest share of clinically documented OUD (a finding aligning with other KFF work), with 12.4% of pregnant and postpartum Medicaid enrollees having a clinically documented OUD. In contrast, Nebraska records the lowest rate of diagnosed OUD, with fewer than 1% of pregnant and postpartum Medicaid enrollees having a clinically documented OUD (Figure 1). Rates of diagnosed OUD vary across state, not only because of prevalence, but also because of other factors such as provider screening behavior, variation in Medicaid coverage of SUD services and state laws criminalizing maternal drug use.

State laws that take a punitive approach toward substance use during pregnancy may contribute to lower OUD diagnosis and treatment. State legislation pertaining to drug use during pregnancy usually falls into punitive or supportive categories. Punitive laws categorize prenatal drug use as a form of child abuse or neglect and necessitate healthcare professionals report these instances to state child welfare agencies. These laws may deter pregnant people from seeking standard prenatal care, substance use treatment, and increase fear and concern over the potential loss of custody of their children due to the involvement of child welfare agencies. Alternatively, supportive drug use legislations attempt to prioritize pregnant and postpartum people’s access to treatment. Professional groups, such as ACOG and ASAM, oppose the use of policies and practices that criminalize drug use in pregnancy and advocate for comprehensive and evidence-based care.

Larger shares of White pregnant and postpartum Medicaid enrollees and those over the age of 25 had a documented OUD compared to Black and Hispanic pregnant and postpartum enrollees and those age 25 and younger. OUD is documented five times more in the claims of White enrollees, with 5.5% having a clinically documented OUD, compared to around 1% of Black and Hispanic enrollees. In addition, clinically documented OUD was more common among enrollees who were 26 and older (3.7% between 26-34 years old and 3.1% for those 35 years and older), compared to those aged 25 or younger (1.6%) (Figure 2). The rates at which OUD is diagnosed and documented can differ among populations due to several factors. Apart from the actual prevalence of the condition, these variations can stem from unequal access to prenatal care, inconsistencies in how providers screen for the disorder, and heightened stigma for certain groups that may amplify repercussions of admitting drug use.

What Percentage of Pregnant and Postpartum Women with a Clinically Documented OUD Received MOUD Treatment?

Overall, just over half (55%) of enrollees received MOUD as part of their care (Figure 3). Despite a little more than half of pregnant and postpartum Medicaid enrollees with a clinically documented OUD showing receipt of MOUD treatment, this is still likely an overestimate of treatment access. Research suggests that OUD prevalence is likely higher than what is reported in claims data. Yet, the number of people receiving MOUD treatment is probably fairly accurate. Therefore, the percentage of enrollees with opioid use disorder – whether documented in claims data or not – who receive treatment is likely lower than 55%.

State treatment rates of pregnant and postpartum Medicaid enrollees with a documented OUD also vary substantially. States where more than 60% of enrollees with a clinically documented OUD received MOUD included Northeastern states (ME, VT, NH, MA, CT, DE) and WA, NM, WI, and OH. On the other hand, in KS, less than 1 in 5 received MOUD. Please refer to Methods and Appendix 2 for more information.

Rates of MOUD treatment vary across states because of factors such as Medicaid utilization controls and variation in engagement in public health initiatives like the development of perinatal collaboratives focusing on OUD throughout the perinatal period or the receipt of SAMHSA grants. Utilization control measures, like prior authorization, shape the access and availability of MOUD and can be a barrier to care, particularly if prior authorization denial rates are high. These measures include prior authorization, quantity limits, step therapy, and psychosocial treatment requirements. In addition to prior authorization requirements, some states also have additional administrative requirements, which may include random drug screenings or pill counts, mandatory counseling requirements, and maximum daily doses.

Additionally, MOUD utilization and adherence are affected by treatment concerns and scarcity of women- centered programs. Prior research finds that pregnant and postpartum individuals express concerns about lack of autonomy in their decision to initiate MOUD and have felt pressured from clinicians, ultimately impacting their commitment to treatment. Other pregnant and postpartum individuals voice concerns about their infants developing NAS and the increased scrutiny they would receive from healthcare staff. Lastly, postpartum parents have highlighted that treatment environments for MOUD are not accommodating to their unique needs. Because methadone and buprenorphine are subject to federal and state restrictions limiting their accessibility, postpartum parents have highlighted the difficulties in maintaining adherence with competing childcare responsibilities. Other challenges affecting adherence in the postpartum period include cost, transportation, lack of continued healthcare coverage after delivery, and shortage of treatment centers and clinicians providing MOUD. Research has shown that women-centered programs – programs that offer services tailored to women’s unique needs – have higher retention rates and reductions in substance use, and fewer reported barriers to care.

Black women with a diagnosed OUD were less likely to receive MOUD during prenatal or postpartum periods (31%) compared to Hispanic and White women (53-57% respectively). However, treatment rates were similar between White and Hispanic pregnant and postpartum enrollees. Research suggests that structural racism may be associated with lower standards of care, fewer treatment options, and higher rates of prosecution of women of color, especially Black women. Black women who use drugs are more likely to be reported to child welfare agencies and drug tested than other women. These factors may make women of color less likely to disclose opioid use and contribute to lower treatment rates. Additionally, the absence of a diverse healthcare workforce may result in reluctance to seek or continue treatment. Prior studies have also drawn attention to the limited diversity of workforce in outpatient substance use treatment settings. Furthermore, the existing knowledge base may not be reflective of the experiences of women of color, with previous research noting that White women with an OUD made up most of their sample. Regarding age, pregnant and postpartum women 26 years and older (56-57%) with diagnosed OUD were more likely to receive MOUD treatment compared to those 25 years old and younger (48%) (Figure 4).

What Changes have been made at the Federal and State Level to Support Pregnant and Postpartum Individuals Diagnosed with Opioid Use Disorder?

In recent years, state and federal governments have undertaken additional actions to address gaps in treatment, prevention, and recovery of substance use disorder services. In 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT Act), a bipartisan legislation, was passed that included Medicaid provisions to expand research and services for pregnant women with OUD. At the same time, CMS launched the Maternal Opioid Misuse (MOM) Model Initiative to address fragmentation in the care of pregnant and postpartum Medicaid enrollees with OUD. There are currently 8 states participating in the program and interventions focus on service integration, coordination, and expansion to ultimately improve the cost, quality, and access to OUD services. In 2021, states were given the option to extend Medicaid postpartum coverage to 12 months in the American Rescue Plan Act and most states have implemented or plan to implement a 12-month extension. This 12-month postpartum extension gives postpartum Medicaid enrollees more time to receive care, ensuring longer access to OUD treatment services. More recently, the Consolidated Appropriations Act of 2023 led to the elimination of additional registration requirements for the prescribing of buprenorphine (X waiver) to facilitate access to buprenorphine providers; funding support to expand maternal mental health screening programs; maintenance of maternal mental health hotline; and establishment of a maternal mental health task force.

Looking Ahead

Although federal policies have aimed to improve access to OUD, treatment gaps persist. Most recently, the resumption of Medicaid renewals following a three-year pandemic halt – termed ‘Medicaid unwinding’ – has led to many individuals being dropped from Medicaid, primarily due to procedural rather than eligibility reasons. While some people losing Medicaid may already have another source of coverage or be able to transition to another form of insurance like the Affordable Care Act marketplace, other pregnant and postpartum women who qualify for Medicaid through pathways other than a current or recent pregnancy may experience coverage loss. Such a loss may disrupt treatment for OUD, increasing overdose risks, especially in the midst of the ongoing fentanyl crisis. If Medicaid unwinding coverage losses disproportionately affect people of color, it could intensify existing racial and ethnic disparities in access to MOUD.

Medicaid Claims (T-MSIS) & State Exclusion Criteria  KFF used the 2016-2019 Transformed Medicaid Statistical Information System (T-MSIS): demographic eligibility base (DE) (2017 and 2018) and both header and line files from inpatient (IP), other services (OT), and long-term care, as well as the prescription (RX) line files from 2016-2019. The 2016-2018 files were Release 2 and the 2019 files were Release 1.

We use 39 states in the main analysis and for maternal age. States with “unusable” data based on state-level information available from the DQ Atlas were excluded. We further excluded states whose final sample in this analysis had a difference of 20% or more from the number of Medicaid-covered births in the CDC Wonder Natality Files and state birth reports. For the analysis on race/ethnicity, we used 24 states with race/ethnicity data that was not considered of “high concern” or “unusable” by the DQ Atlas. Data reported in this analysis are from states with useable and sufficient (n > 50) data. Please see Appendix Table 1 for more information on the measures we used from the DQ Atlas, CDC Wonder Natality Files, and state birth reports to assess states’ data quality.

T-MSIS Enrollee Sample Selection  The sample includes pregnant and postpartum Medicaid enrollees that had a live birth in 2017 and 2018. Enrollees were not included if they did not have a live birth within the study period. This analysis defined the prenatal period as 10 months prior to delivery and the postpartum period includes delivery and 60 days post-delivery. After enrollee and data quality exclusions, the sample includes 2,368,069 enrollees with a live birth from 39 states. Among those with a live birth, 65,092 enrollees had a documented OUD. Out of those with a clinically documented OUD, 35,612 received MOUD.

For the analysis on age, there were 970,458 live births among those 25 years old and younger, 1,084,572 live births among those 26-34 years old, and 313,039 live births among those 35 years old and older across 39 states. Out of those with a live birth, there were 15,234 25 years old and younger, 40,143 between 26-34 years old, and 9,715 35 years old and older with a documented OUD. There were 7,277 enrollees 25 years old and younger, 22,926 enrollees between 26-34 years old, and 5,409 enrollees 35 years old and older that had at least one claim for MOUD.

For the analysis on race/ethnicity, there were 633,477 White live births, 324,546 Black live births, and 527,147 Hispanic live births across 24 states. Out of those with a live birth there were 34,899 White enrollees, 3,447 Black enrollees, and 3,279 Hispanic enrollees who had a clinically documented OUD. Among those with a documented OUD, 19,960 White enrollees, 1,074 Black enrollees, and 1,749 Hispanic enrollees that had at least one claim for MOUD. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis. Other groups are considered non-Hispanic.

Identification of OUD and Treatment in T-MSIS  We link header and line files using BENE_ID and CLM_ID. DE files are linked to header and line files using BENE_ID and if BENE_ID is missing, MSIS_ID. To identify OUD diagnoses and MOUD, we used the Behavioral Health Service Algorithm (BHSA) reference codes provided by Urban Institute (Victoria Lynch, Lisa Clemans-Cope, Paul Johnson, Marni Epstein, Doug Wissoker, and Emma Winiski. Behavioral Health Services Algorithm. Version 3. Washington, DC: Urban Institute, 2022.) which uses ICD-9 and ICD-10 diagnosis codes, procedure codes, service codes, and National Drug Codes (NDCs).

The OUD definition that was used for this analysis included all F11 diagnosis codes, procedure codes for naltrexone unique to OUD (G2073, G2074, G2075), procedure codes for methadone maintenance (HZ91ZZZ, HZ81ZZZ, H0020, G2078, G2067), buprenorphine procedure and NDC codes, and other procedure codes unique to OUD (HZ82ZZZ, HZ92ZZZ, M1032, M1033, M1034, M1035, M1036). One or more occurrence of these codes was coded as an OUD. Modifications to the BHSA algorithm include the removal of NDC codes that were not specific to OUD. Approximately, 2% of pregnant and postpartum Medicaid enrollees had only an Rx prescription and were considered to have an OUD diagnosis.

MOUD treatment included enrollees with at least one of the following: procedure codes for methadone maintenance (HZ91ZZZ, HZ81ZZZ, H0020, G2078, G2067), buprenorphine procedure and NDC codes, and other procedure codes unique to OUD (HZ82ZZZ, HZ92ZZZ, M1032, M1033, M1034, M1035, M1036), procedure codes for naltrexone unique to OUD (G2073, G2074, G2075), and naltrexone NDC codes among those with an OUD diagnosis. Naltrexone is also used for the treatment of alcohol use disorder (AUD) and we did not include those that did not have a corresponding OUD diagnosis code. As previously mentioned, we used reference codes from the Behavioral Health Services Algorithm developed by the Urban Institute.

KFF estimates that there are over 4 million people using Medicaid home- and community-based services (HCBS), which include medical and supportive services that assist people with the activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medications, and housekeeping). They are provided to people who need such services because of aging, chronic illness, or disability and may include personal care, adult daycare, home health aide services, transportation, and supported employment. Medicare generally does not cover HCBS and in 2020, Medicaid spent $162 billion on HCBS—a majority of the $245 billion in total HCBS spending. Although all states offer some HCBS through Medicaid, most services are optional for states, and states may cover different services for different types of Medicaid enrollees. To be eligible for Medicaid HCBS, individuals must have limited financial resources and significant functional impairments.

During the COVID-19 pandemic, people who use HCBS were at heightened risk of serious illness or death from exposure to COVID-19 and were disproportionately likely to need hospital or nursing facility care when HCBS were unavailable, but there were fewer workers available and willing to provide services. Recognizing those challenges, the federal government provided states with new authorities to maintain access to HCBS during the public health emergency (PHE), which was in place from 2020 until May 11, 2023. Family caregivers played a critical role in helping to mitigate the consequences of workforce shortages and many states used the new authorities to support and pay family caregivers.

Drawing from KFF’s 50-state survey of state Medicaid HCBS officials, conducted between May and August of 2023, this issue brief describes how states used the PHE authorities to strengthen their HCBS programs, changes as the PHE ends, and the role of family caregivers in providing HCBS. Key take-aways include:

• States used PHE authorities to strengthen their HCBS programs by expanding access to services and investing in the HCBS workforce, and while some of those changes are transitioning into permanent policies, others are ending as the PHE authorities expire.
• The most commonly expiring policies will result in the end of virtual evaluations of eligibility and care needs in 23 states, lower utilization limits in 21 states, and reinstated prior authorization in 18 states; changes that may make it harder for Medicaid enrollees to access HCBS or may reduce the amount of HCBS they are able to use (Figure 1).
• Most states now allow family caregivers to be paid for providing personal care, but such payments are most common under waiver programs, which are offered at the states’ discretion and may limit enrollment to people with certain types of disabilities, may cap enrollment or spending at specified levels, and may use waiting lists when the number of people seeking services exceeds the number of waiver slots available.
• In 11 states, payments to family caregivers who are legally responsible for the person they are caring for will be ending and payments to other types of family caregivers will end in 5 states. With ongoing workforce shortages, families may have difficulty finding paid workers to take over their responsibilities when the policies expire.

How did states use public health emergency authorities to support Medicaid HCBS during the pandemic?

In a 2023 survey of states’ Medicaid HCBS programs, all responding states reported using PHE authorities to strengthen their programs by addressing eligibility and enrollment processes, increasing the availability of services, and addressing workforce challenges (Figure 2, Appendix Table 1). Responding states include the District of Columbia and all states except for Florida. The most common changes included allowing virtual evaluations of people’s eligibility for HCBS or the level of care needed (49 states), increasing payment rates to providers (45 states), allowing spouses and parents of minor children or other legally responsible relatives to be paid providers (37 states), increasing utilization limits on existing services (35 states), and allowing other family members or friends to be paid providers (27 states).

States made these changes using several types of authorities when responding to the COVID-19 PHE, including disaster-relief state plan amendments, 1115 waivers, and Appendix K changes to 1915(c) waivers. When the PHE ended on May 11, 2023, changes made through a disaster-relief state plan amendment or 1115 waiver also ended unless they had been moved to a permanent authority. Changes made using the Appendix K authority will expire within 6 months of the PHE ending (November 11, 2023) unless the state incorporates those changes into section 1915(c) waiver programs.

Although nearly all states are making some of their changes permanent, many other PHE-era policies are ending as the authorities expire. Among states responding to the survey, all states except for Kentucky and New Jersey plan to keep at least one of the policies that they enacted during the PHE. Some policies have already been made permanent—most commonly, increased payment rates (33 states), virtual evaluations of eligibility or level of care (20 states) and allowing family caregivers to be paid providers (17 states). Other policies are currently being transitioned from temporary to permanent authorities, with 13 states currently in the process of transitioning a policy allowing spouses, parents of minor children, or other legally responsible relatives to be paid providers. In other cases, the policies enacted during the PHE are ending, with 23 states ending virtual evaluations of eligibility or level of care, 21 states ending higher utilization limits, and 18 states reinstating prior authorization.

As the public health emergency authorities end, how are states supporting family caregivers?

The availability of payments for and support of family caregivers increased during the PHE and even as PHE authorities end, nearly all states allow payments to family caregivers for at least one of their HCBS programs (Figure 3, Appendix Table 2). Payments for family caregivers are generally allowed for the provision of personal care, which may be offered through several different types of Medicaid HCBS programs. Personal care may be provided through waivers such as 1115 or 1915(c) programs, through the Medicaid state plan, or a combination of both. Waiver services tend to encompass a wider range of benefits than the state plan benefit, but waivers are usually restricted to specific groups of Medicaid enrollees based on geographic region, income, or type of disability; and are often only available to a limited number of people, resulting in waiting lists. In 2023, all 50 states and DC offered HCBS through at least one waiver and 34 states offered personal care as a state plan benefit.

States were more likely to allow family caregivers to be paid if they were not legally responsible for the person receiving care and if the person receiving care was enrolled in an HCBS waiver. Among the 50 states with HCBS waivers that responded to the survey, 41 states allow payments to spouses, parents of minor children, and other legally responsible relatives and 49 states allow payments for other family members and friends (those who are not legally responsible relatives). Among the 34 states providing personal care through the Medicaid state plan, 12 states allow payments to legally responsible relatives and 23 states allow payments to other family members and friends. Those numbers include states that allow payments to family caregivers on an ongoing basis and states that only authorized such payments through a PHE authority. The totals also include states that allow payments for family caregivers under at least one of their waivers, but most states have more than one waiver, and such payments may not be permitted under all waivers.

Payments to legally responsible relatives are more likely to end after the PHE authorities expire than are payments to other family and friends. For the state plan benefit, the number of states only paying family members under a PHE authority was 6 states for legally responsible relatives (Alaska, Idaho, Louisiana, Minnesota, New Hampshire, and Oklahoma) and 2 states for other family members and friends (Missouri and New Hampshire). For waiver programs, the number of states that only allowed payments for family caregivers under a PHE authority for any waiver program in the state was 8 states for legally responsible relatives (Alaska, Georgia, Idaho, Iowa, New Jersey, Rhode Island, Vermont, and Virginia) and 3 states for other family and friends (Kansas, New Jersey, and Vermont). Because most states have different policies for different waivers, a larger number of states will have payments to family caregivers ending for specific waiver programs as shown in the next figure.

Payments to family caregivers are most common for people with intellectual or developmental disabilities and people who are ages 65 and older or with physical disabilities (Figure 4, Appendix Table 3). Most state waiver programs are limited to people with specific types of disabilities—most commonly, intellectual or developmental disabilities (48 states) and people who are ages 65 and older or have physical disabilities (45 states). Among the states with waivers for people with intellectual or developmental disabilities, 18 states allow payments to legally responsible relatives and 43 states allow payments to other family and friends. Among the states with waivers for people who are ages 65 and older or with physical disabilities, 18 states allow payments to legally responsible relatives and 17 states allow payments to other family and friends.

Several states report that payments to family caregivers will end when the PHE authorities expire. Payments to legally responsible relatives were allowed under the PHE but will be ending in 9 states with waivers for people with intellectual and developmental disabilities, in 7 states with waivers for people who are ages 65 and older or with physical disabilities, in 2 states for people with traumatic brain or spinal cord injuries, and in 2 states for children who are medically fragile or technology dependent. (These numbers are higher than the numbers reported overall in Figure 3 because many states allow payments for family caregivers indefinitely for some waivers but only temporarily for other waivers.)

Nearly all states now provide support for family caregivers—who may be paid or unpaid—and most states offer more than one type of support (Figure 5, Appendix Table 4). Almost all (49) states offer at least one family caregiving support in their HCBS programs, and 39 states offer more than one family caregiving support. These supports frequently include respite care (49 states), caregiver training (33 states), and caregiver counseling/support groups (24 states). For all types of waivers, respite care was the most frequently reported support offered and caregiver counseling or support groups was the least frequently reported.

What challenges might Medicaid enrollees who use HCBS face as the PHE ends?

As the PHE authorities expire, there may be additional barriers to accessing HCBS in some states. Although many states are working to make the PHE changes permanent, 23 states will cease evaluating eligibility virtually, 2 states will reduce financial eligibility, 3 states will reduce functional eligibility, and 2 states will reduce the number of waiver slots. Concurrently, 21 states will reinstate utilization limits and 18 states will reinstate prior authorization. Some of those changes will reduce the number of people who are eligible for HCBS or reduce the amount of HCBS eligible enrollees may use.

New HCBS-related administrative barriers could exacerbate the challenges Medicaid enrollees are already experiencing from the unwinding of the pandemic-era continuous enrollment provision, which has resulted in 6.5 million Medicaid enrollees losing coverage as of September 15, 2023. Between February 2020 and March 2023, states received enhanced federal Medicaid funding for keeping people continuously enrolled in Medicaid, and states are now redetermining eligibility for all Medicaid enrollees. Although most people who use HCBS are unlikely to have income or employment changes that render them ineligible for Medicaid, they must still demonstrate their continued eligibility, and some could lose coverage for procedural reasons.

Beyond administrative hurdles, the end of the PHE authorities may place further strain on the HCBS workforce and on family caregivers who provide HCBS. Many of the PHE authorities were enacted in response to HCBS workforce shortages that were exacerbated by the COVID-19 pandemic. As the pandemic era ends, employment in the long-term services and supports sectors continues to remain below pre-pandemic levels and it is unclear whether HCBS workforce shortages will become worse.

In states where payments for family caregivers are ending for some HCBS programs, family members will need to either find new paid workers or will continue to provide care but be unpaid for those services. This situation will be most common for legally responsible relatives who are caring for people with intellectual or developmental disabilities. In states where payments for family caregivers are continuing, such caregivers may experience changes in states’ requirements related to training, documentation, or the maximum number of hours for which they are paid as policies transition to permanent.

Challenges for family caregivers and the HCBS workforce reflect broader challenges in providing care to the many people who use long-term services and supports (LTSS) in both HCBS and institutional settings. The pandemic affected health care workers in all settings but particularly among workers who provide LTSS. As of June 2023, employment levels were still more than 11% below pre-pandemic levels for workers in skilled nursing care facilities and 3% below pre-pandemic levels for workers in elderly care facilities. Recognizing the significance of the LTSS workforce shortage, the Biden Administration has undertaken several steps to bolster the workforce which include issuing major new rules aimed at strengthening the workforce. In HCBS settings, a recent proposed rule on Medicaid access would require states to demonstrate that their payment rates for HCBS are “adequate to ensure a sufficient direct care workforce to meet the needs of beneficiaries and provide access to services.” The rule would also require states to demonstrate that at least 80% of total payments for certain HCBS were compensation to direct care workers. In institutional settings, a recent proposed rule on nursing facility staffing would require facilities to meet minimum staffing requirements and would require states to report on what percentage of Medicaid payments were compensation to direct care workers. Those rules highlight the commitment to supporting LTSS workers, but ultimately, there are only so many people available to provide LTSS and it is likely that challenges will persist.

The Survey of Immigrants, a partnership between KFF and The Los Angeles Times, takes an in-depth look at the experiences of immigrants, a diverse group that makes up 16% of the U.S. adult population. Immigrants play an important role in the nation’s workforce and culture, and they also face unique experiences and struggles in their communities, workplaces, and health care settings. Nonetheless, they overwhelmingly express optimism about their futures in the U.S. and have high hopes for their children.

The survey is the largest nationally representative survey focused on immigrants, interviewing 3,358 immigrant adults in 10 languages. The results provide a deep understanding of immigrants’ experiences, reflecting their varied countries of origin and histories, immigration statuses, racial and ethnic identities, and socioeconomic backgrounds. In addition to the survey, KFF and The Los Angeles Times also conducted 13 focus groups with immigrant adults across the country.

Other KFF reports from the survey:

Health and Health Care Experiences of Immigrants

Political Preferences and Views on U.S. Immigration Policy Among Immigrants in the U.S.

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

Most Hispanic Immigrants Say Their Lives Are Better In The U.S. But Face Financial And Health Care Challenges: The 2023 KFF/LA Times Survey of Immigrants

Five Key Facts About Immigrants’ Understanding of U.S. Immigration Laws, Including Public Charge

Five Key Facts About Immigrants with Limited English Proficiency

Five Key Facts About Black Immigrants’ Experiences in the United States

Explore The Los Angeles Times’ “Immigrant Dreams” project:

In an increasingly pessimistic era, immigrants espouse a hallmark American trait — optimism, published Sept. 17, 2023

Ten languages, thousands of phone calls: Accurately polling immigrants posed unprecedented challenges, published Sept. 17, 2023

Column: We need immigrants more than ever. They keep hope in this country alive, published Sept. 17, 2023

Receiving food stamps won’t kill your green card chances. How ‘public charge’ works, published Sept. 17, 2023

Immigration scams are rampant. Here’s how to avoid getting taken, published Sept. 17, 2023

We asked immigrants across the country these questions. See how your answers line up, published Sept. 17, 2023

Black immigrants face more discrimination in the U.S. The source is sometimes surprising, published Sept. 21, 2023

Low wages, lousy shifts, little room for advancement: Immigrant workers describe on-the-job discrimination, published Oct. 19, 2023

‘Everything’s like a gamble’: U.S. immigration policies leave lives in limbo, published Nov. 30, 2023

Column: Are immigrants better off in Texas or California? It’s complicated, published Nov. 30, 2023

Column: Could immigrants be America’s new swing voter group, published Nov. 30, 2023

Medi-Cal will soon be open to all, ‘papers or no papers.’ She wants her neighbors to know, published Dec. 24, 2023

Executive Summary

The Survey of Immigrants, conducted by KFF in partnership with the Los Angeles Times during Spring 2023, examines the diversity of the U.S. immigrant experience. It is the largest and most representative survey of immigrants living in the U.S. to date. With its sample size of 3,358 immigrant adults, the survey provides a deep understanding of immigrant experiences, reflecting their varied countries of origin and histories, citizenship and immigration statuses, racial and ethnic identities, and social and economic circumstances. KFF also conducted focus groups with immigrants from an array of backgrounds, which expand upon information from the survey (see Methodology for more details).

This report provides an overview of immigrants’ reasons for coming to the U.S.; their successes and challenges; their experiences at work, in their communities, in health care settings, and at home; as well as their outlook on the future. Recognizing the diversity within the immigrant population, the report examines variations in the experiences of different groups of immigrants, including by immigration status, income, race and ethnicity, English proficiency, and other factors. Given that this report includes a focus on experiences with discrimination and unfair treatment, data by race and ethnicity are often shown rather than by country of birth. A companion report provides information on immigrants’ health coverage, access to, and use of care, and further reports will provide additional details for other subgroups within the immigrant population, including more data by country of origin.

Key takeaways from this report include:

• Most immigrants – regardless of where they came from or how long they’ve been in the U.S. – say they came to the U.S. for more opportunities for themselves and their children. The predominant reasons immigrants say they came to the U.S. are for better work and educational opportunities, a better future for their children, and more rights and freedoms. Smaller but still sizeable shares cite other factors such as joining family members or escaping unsafe or violent conditions.
• Overall, a majority of immigrants say their financial situation (78%), educational opportunities (79%), employment situation (75%), and safety (65%) are better as a result of moving to the U.S. A large majority (77%) say their own standard of living is better than that of their parents, higher than the share of U.S.-born adults who say the same (51%)¹ ,and most (60%) believe their children’s standard of living will be better than theirs is now. Three in four immigrants say they would choose to come to the U.S. again if given the chance, and six in ten say they plan to stay in the U.S. However, about one in five (19%) say they want to move back to the country they were born in or to another country, while an additional one in five (21%) say they are not sure.
• Despite an improved situation relative to their countries of birth, many immigrants report facing serious challenges, including high levels of workplace and other discrimination, difficulties making ends meet, and confusion and fears related to U.S. immigration laws and policies. These challenges are more pronounced among some groups of immigrants, including those who live in lower-income households, Black and Hispanic immigrants, those who are likely undocumented, and those with limited English proficiency. Given the intersectional nature of these factors, some immigrants face compounding challenges across them.
• Most immigrants are employed, and about half of all working immigrants say they have experienced discrimination in the workplace, such as being given less pay or fewer opportunities for advancement than people born in the U.S., not being paid for all their hours worked, or being threatened or harassed. In addition, about a quarter of all immigrants, rising to three in ten of those with college degrees, say they are overqualified for their jobs, a potential indication that they had to take a step back in their careers when coming to the U.S. or lacked career advancement opportunities in the U.S.
• About a third (34%) of immigrants say they have been criticized or insulted for speaking a language other than English since moving to the U.S., and a similar share (33%) say they have been told they should “go back to where you came from.” About four in ten (38%) immigrants say they have ever received worse treatment than people born in the U.S. in a store or restaurant, in interactions with the police, or when buying or renting a home. Some immigrants also report being treated unfairly in health care settings. Among immigrants who have received health care in the U.S., one in four say they have been treated differently or unfairly by a doctor or other health care provider because of their racial or ethnic background, their accent or how well they speak English, or their insurance status or ability to pay for care.
• Immigrants who are Black or Hispanic report disproportionate levels of discrimination at work, in their communities, and in health care settings. Over half of employed Black (56%) and Hispanic (55%) immigrants say they have faced discrimination at work, and roughly half of college-educated Black (53%) and Hispanic (46%) immigrant workers say they are overqualified for their jobs. Nearly four in ten (38%) Black immigrants say they have been treated unfairly by the police and more than four in ten (45%) say they have been told to “go back to where you came from.” In addition, nearly four in ten (38%) Black immigrants say they have been treated differently or unfairly by a health care provider. Among Hispanic immigrants, four in ten (42%) say they have been criticized or insulted for speaking a language other than English.
• Even with high levels of employment, one third of immigrants report problems affording basic needs like food, housing, and health care. This share rises to four in ten among parents and about half of immigrants living in lower income households (those with annual incomes under $40,000). In addition, one in four lower income immigrants say they have difficulty paying their bills each month, while an additional 47% say they are “just able to pay their bills each month.”
• Among likely undocumented immigrants, seven in ten say they worry they or a family member may be detained or deported, and four in ten say they have avoided things such as talking to the police, applying for a job, or traveling because they didn’t want to draw attention to their or a family member’s immigration status. However, these concerns are not limited to those who are likely undocumented. Among all immigrants regardless of their own immigration status, nearly half (45%) say they don’t have enough information to understand how U.S. immigration laws affect them and their families, and one in four (26%) say they worry they or a family member could be detained or deported. Confusion and lack of information extend to public charge rules. About three quarters of all immigrants, rising to nine in ten among likely undocumented immigrants, say they are not sure whether use of public assistance for food, housing, or health care can affect an immigrant’s ability to get a green card or incorrectly believe that use of this assistance will negatively affect the ability to get a green card.
• About half of all immigrants have limited English proficiency, and about half among this group say they have faced language barriers in a variety of settings and interactions. About half (53%) of immigrants with limited English proficiency say that difficulty speaking or understanding English has ever made it hard for them to do at least one of the following: get health care services (31%); receive services in stores or restaurants (30%); get or keep a job (29%); apply for government financial help with food, housing, or health coverage (25%); report a crime or get help from the police (22%). In addition, one-quarter of parents with limited English proficiency say they have had difficulty communicating with their children’s school (24%). Working immigrants with limited English proficiency also are more likely to report workplace discrimination compared to those who speak English very well (55% vs. 41%).

Why Do Immigrants Come to The U.S. And How Do They Feel About Their Life in the U.S.?

Immigrants cite both push and pull factors as reasons for coming to the U.S. For most immigrants, their major reasons for coming to the U.S. are aspirational, such as seeking better economic and job opportunities (75% say this is a major reason they came to the U.S.), a better future for their children (68%), and for better educational opportunities (62%). Half of immigrants say a major reason they or their family came to the U.S. was to have more rights and freedoms, including about three-quarters of immigrants from Central America (73%). Smaller but sizeable shares say other factors such as joining family members (42%) or escaping unsafe or violent conditions (31%) were major reasons they came. The share who cites escaping unsafe conditions as a major reason for coming to the U.S. rises to about half of likely undocumented immigrants (51%) and about six in ten (59%) immigrants from Central America.

Most immigrants say moving to the U.S. has provided them more opportunities and improved their quality of life. When the survey asked immigrants to describe in their own words the best thing that has come from moving to the U.S., many similar themes arise: better opportunities, a better life in general, or a better future for their children are top mentions, as are education and work opportunities.

Most immigrants feel that moving to the U.S. has made them better off in terms of educational opportunities (79%), their financial situation (78%), their employment situation (75%), and their safety (65%). Safety stands out as an area where somewhat fewer –though still a majority–immigrants say they’re better off, particularly among White and Asian immigrants. A bare majority (54%) of Asian immigrants and fewer than half (42%) of White immigrants say their safety is better as a result of moving to the U.S., while about one in five in both groups (17% of Asian immigrants and 21% of White immigrants) say they are less safe as a result of coming to the U.S.

Most immigrants say they are better off compared with their parents at their age, and most are optimistic about their children’s future. When asked about their standard of living, three quarters (77%) of immigrants say their standard of living is better than their parents’ was at their age. This is substantially higher than the share of U.S.-born adults who say the same (51%). Many expect an even better future for their children. Six in ten immigrants believe their children’s standard of living will be better than theirs is now, with much smaller shares saying they think it will be worse (13%) or about the same (17%). Most immigrant parents also have positive feelings about the education their children are receiving. About three in four (73%) immigrant parents rate their child’s school as either “excellent” (35%) or “good” (38%), with a further one-sixth (17%) saying the school is “fair,” and 3% give it a “poor” rating.

How Are Immigrants Faring Economically?

Like many U.S. adults overall, immigrants’ biggest concerns relate to making ends meet: the economy, paying bills, and other financial concerns. When asked in the survey to name the biggest concern facing them and their families in their own words, about one-third of immigrants gave answers related to financial stability or other economic concerns. No other concern rose to the level of financial concerns, though other common concerns mentioned include health and medical issues, safety, work and employment issues, and immigration status.

One in three immigrants report difficulty paying for basic needs. About one in three immigrants (34%) say their household has fallen behind in paying for at least one of the following necessities in the past 12 months: utilities or other bills (22%), health care (20%), food (17%), or housing (17%). The share who reports problems paying for these necessities rises to about half among immigrants who have annual household incomes of less than $40,000 (47%). The shares who report facing these financial challenges are also larger among immigrants who are likely undocumented (51%), Black (50%), or Hispanic (43%), largely because they are more likely to be low income. Additionally, four in ten immigrant parents report problems paying for basic needs.

Beyond having trouble affording basic needs, a sizeable share of immigrants report they are just able to or have difficulties paying monthly bills. Nearly half (47%) of immigrants overall say they can pay their monthly bills and have money left over each month, while four in ten (37%) say they are just able to pay their bills and about one in six (15%) say they have difficulty paying their bills each month. Affordability of monthly bills varies widely by income as well as race and ethnicity. For example, only about a quarter (27%) of lower income immigrants say they have money left over after paying monthly bills compared with eight in ten (80%) of those with at least $90,000 in annual income. About six in ten immigrants who are White or Asian say they have money left over after paying their bills each month compared with four in ten Hispanic immigrants and one-third (32%) of Black immigrants, reflecting lower incomes among these groups.

Despite these financial struggles, close to half of immigrants say they send money to relatives or friends in their country of birth at least occasionally. Overall, about one in three (35%) immigrants say they send money occasionally or when they are able. Much smaller shares report sending either small (8%) or large (2%) shares of money on a regular basis, and overall, most immigrants (55%) do not send money to relatives or family outside the U.S.

Similar shares of immigrants report sending money to their birth country regardless of their own financial struggles. About half (49%) of those who have difficulty paying their bills each month say they send money at least occasionally, as do 44% of those who say they just pay their bills and the same share of those who have money left over after paying monthly bills. Two-thirds (65%) of Black immigrants say they send money to their birth country at least occasionally, while about half (52%) of Hispanic immigrants and four in ten Asian immigrants (42%) report sending money. A much smaller share (24%) of White immigrants say they send money to the country where they were born.

What Are Immigrants’ Experiences In The Workplace?

Two-thirds of immigrants say they are currently employed, including nearly seven in ten of those under age 30, about three quarters of those between the ages of 30-64, and a quarter of those ages 65 and over. The remaining third include a mix of students, retirees, homemakers, and few (6%) unemployed immigrants. A quarter of working immigrants say they are self-employed or the owner of a business, rising to one-third (34%) of White working immigrants and nearly three in ten (27%) Hispanic working immigrants. Jobs in construction, sales, health care, and production are the most commonly reported jobs among working immigrants. KFF analysis of federal data shows that immigrants are more likely to be employed in construction, agricultural, and service jobs than are U.S.-born citizen workers.

About a quarter of working immigrants feel they are overqualified for their job, rising to half of college-educated Black and Hispanic immigrants. A majority of working immigrants overall (68%) say they have the appropriate level of education and skills for their job, while about a quarter (27%) say they are overqualified, having more education and skills than the job requires. Just 4% say they are underqualified, having less education and skills than their job requires. In an indication that some immigrants are unable to obtain the same types of roles they were educated and trained for in the countries they came from, the share who feel overqualified for their current job rises to 31% among immigrants with college degrees. It is even higher among college-educated Black (53%) and Hispanic (46%) immigrants.

Overall, about half of employed immigrants report working jobs that pay them by the hour (52%), one third say they are paid by salary (32%), and 15% report being paid by the job. However, these shares vary by income, immigration status, educational attainment, and race and ethnicity. Compared to immigrants with higher incomes, immigrants with lower incomes are more likely to be paid by the hour (63% of immigrants with annual household incomes of less than $40,000) or by the job (24%) than receive a salary (13%). Immigrants who are likely undocumented (30%) are about twice as likely as those with a green card or visa (14%) or naturalized citizens (12%) to report being paid by the job, and about half as likely to report being paid by salary (17%, 32%, and 36%, respectively). Immigrants with a college degree are more than three times as likely as those without a college degree to hold salaried jobs, (57% vs. 16%). Black and Hispanic immigrants are more likely to report working hourly jobs (69% and 60% respectively) than their White (42%) and Asian (40%) counterparts. Conversely, among those who are employed, almost half of Asian immigrants and more than four in ten White immigrants report being paid by salary compared with a quarter or fewer Black and Hispanic immigrants.

About half of working immigrants report experiencing discrimination at work. About half (47%) of all working immigrants say they have ever been treated differently or unfairly at work in at least one of five ways asked about on the survey, most commonly being given fewer opportunities for advancement (32%) and being paid less (29%) compared to people born in the U.S. About one in five working immigrants say they have not been paid for all their hours or overtime (22%) or have been given undesirable shifts or less control over their work hours than someone born in the U.S. doing the same job (17%). About one in ten (12%) say they have been harassed or threatened by someone in their workplace because they are an immigrant.

Highlighting the intersectional impacts of race, ethnicity, and immigration status, reports of workplace discrimination are higher among immigrant workers of color and likely undocumented immigrants. Majorities of Black (56%) and Hispanic (55%) immigrant workers report experiencing at least one form of workplace discrimination asked about. More than four in ten (44%) Asian immigrant workers also report experiencing workplace discrimination compared to three in ten (31%) White immigrant workers. About two-thirds (68%) of likely undocumented working immigrants report experiencing at least one form of unfair treatment in the workplace, with about half of this group saying they have been paid less or had fewer opportunities for advancement than people born in the U.S. for doing the same job. Undocumented immigrant workers often face even greater employment challenges due to lack of work authorization, which increases risk of potential workplace abuses, violations of wage and hour laws, and poor working as well as living conditions.

Limited English proficiency is also associated with higher levels of reported workplace discrimination. A majority (55%) of working immigrants who speak English less than very well (rising to 61% of Hispanic immigrants with limited English proficiency) report experiencing at least one form of workplace discrimination. In particular, immigrants with limited English proficiency are more likely than those who are English proficient to say they were given fewer opportunities for promotions or raises (38% vs. 27%) or were paid less than people born in the U.S. for doing the same job (34% vs. 24%).

Do Immigrants Feel Welcome In The U.S.?

Most immigrants feel welcome in their neighborhoods. Overall, two-thirds of immigrants say most people in their neighborhoods are welcoming to immigrants. Just 7% say people in their neighborhood are not welcoming, while one in four say they are “not sure” whether immigrants are welcome in their neighborhood. When it comes to the treatment of immigrants in the state in which they live, about six in ten immigrants say they feel people in their state are welcoming to immigrants, but 15% say their state is not welcoming and another one in four say they are “not sure.” When asked about whether they think most people are welcoming to immigrants outside of the state in which they live, about half (48%) of immigrants say they are “not sure” about this, which could reflect lack of experiences in other places.

Immigrants in Texas are much less likely than those in California to feel their state is welcoming to immigrants. Immigrants living in California and Texas, the two most populous states for immigrants, are about equally likely to say immigrants are welcome in their neighborhood. However, immigrants living in California are about 30 percentage points more likely than are immigrants living in Texas to say they feel people in their state are welcoming to immigrants (70% vs. 39%). Further, immigrants in Texas are more than three times as likely as those in California to say they feel their state is not welcoming to immigrants (31% vs. 8%).

What Are Immigrants’ Experiences With Discrimination And Unfair Treatment In The Community?

Despite feeling welcome in their neighborhoods, many immigrants report experiencing discrimination and unfair treatment in social and police interactions. About four in ten (38%) immigrants say they have ever received worse treatment than people born in the U.S. in at least one of the following places: in a store or restaurant (27%), in interactions with the police (21%), or when buying or renting a home (17%). In addition, about a third (34%) of immigrants say that since moving to the U.S., they have been criticized or insulted for speaking a language other than English, and a similar share (33%) say they have been told they should “go back to where you came from.”

Reports of discrimination and unfair treatment are more prevalent among people of color compared to White immigrants, illustrating the combined impacts of racism and anti-immigrant discrimination. For example, about one-third of immigrants who are Black (35%) or Hispanic (31%) and about a quarter (27%) of Asian immigrants say they have ever received worse treatment than people born in the U.S. in a store or restaurant, all higher than the share among White immigrants (16%). Notably, four in ten (38%) Black immigrants say they have ever received worse treatment than people born in the U.S. in interactions with the police, and almost half (45%) say they have been told they should “go back to where you came from.” Among Hispanic immigrants, about four in ten (42%) say they have been criticized or insulted for speaking a language other than English.

One in four immigrants report being treated unfairly by a health care provider. In addition to discrimination at work and in community settings, a sizeable share of immigrants say they have been treated unfairly by a doctor or health care provider since coming to the U.S. Overall, among immigrants who have received health care in the U.S., one in four (rising to nearly four in ten Black immigrants) say they have been treated differently or unfairly by a doctor or other health care provider because of their racial or ethnic background, their accent or how well they speak English, or their insurance status or ability to pay for care. For more details about immigrants’ health and health care experiences, read the companion report here.

What Language Barriers Do Immigrants With Limited English Proficiency Face?

Over half of immigrants with limited English proficiency report language barriers in a variety of settings and interactions. Overall, about half of all immigrants have limited English proficiency, meaning they speak English less than very well. Among this group, about half (53%) say that difficulty speaking or understanding English has ever made it hard for them to do at least one of the following: receive services in stores or restaurants (30%); get health care services (31%); get or keep a job (29%); apply for government assistance with food, housing, or health coverage (25%); or get help from the police (22%).

Language barriers are amplified among those with lower levels of educational attainment as well as those with lower incomes. Among immigrants with limited English proficiency, those who do not have a college degree are more likely to report experiencing at least one of these difficulties than those who have a college degree (57% vs. 39%). Similarly, lower income immigrants (household incomes less than $40,000) with limited English proficiency are more likely to report facing language barriers compared to their counterparts with incomes of $90,000 or more (61% vs. 38%).

Immigrant parents with limited English proficiency also face challenges communicating with their children’s school or teacher. Among immigrant parents with limited English proficiency (52% of all immigrant parents), about one in four (24%) say difficulty speaking or understanding English has made it hard for them to communicate with their child’s school or teacher.

How Do Confusion And Worries About Immigration Laws And Status Affect Immigrants’ Daily Lives?

About seven in ten (69%) immigrants who are likely undocumented worry they or a family member may be detained or deported. However, worries about detention or deportation are not limited to those who are likely undocumented. About one in three immigrants who have a green card or other valid visa say they worry about this, as do about one in ten (12%) immigrants who are naturalized U.S. citizens.

Some immigrants report avoiding certain activities due to concerns about immigration status. Fourteen percent of immigrants overall, rising to 42% of those who are likely undocumented, say they have avoided things such as talking to the police, applying for a job, or traveling because they didn’t want to draw attention to their or a family member’s immigration status. In addition, 8% of all immigrants say they have avoided applying for a government program that helps pay for food, housing, or health care because of concerns about immigration status, including 27% of those who are likely undocumented.

More than four in ten (45%) immigrants overall say they don’t have enough information about U.S. immigration policy to understand how it affects them and their family. Lack of immigration-related knowledge is strongly related to one’s immigration status. Nearly seven in ten (69%) immigrants who are likely undocumented say they don’t have enough information, while immigrants with a valid green card or visa are split, with one half saying they have enough information and the other half saying they do not. Being a naturalized U.S. citizen doesn’t completely diminish immigrants’ confusion about U.S. immigration policy, as nearly four in ten (39%) immigrants who are naturalized citizens also say they don’t have enough information. Beyond immigration status, the groups who are more likely to say they do not have enough information to understand how immigration policy affects them and their families include immigrants with limited English proficiency, those who have been in the U.S. for fewer than five years, have lower household incomes, and/or have lower levels of education.

Across immigrants, there is a general lack of knowledge about public charge rules. Under longstanding U.S. policy, federal officials can deny an individual entry to the U.S. or adjustment to lawful permanent status (a green card) if they determine the individual is a “public charge” based on their likelihood of becoming primarily dependent on the government for subsistence. In 2019, the Trump Administration made changes to public charge policy that newly considered the use of previously excluded noncash assistance programs for health care, food, and housing in public charge determinations. This policy was rescinded by the Biden Administration in 2021, meaning that the use of noncash benefits, including assistance for health care, food, and housing, is not considered for public charge tests, except for long-term institutionalization at government expense. The survey suggests that many immigrants remain confused about public charge rules. Six in ten immigrants say they are “not sure” whether use of public programs that help pay for health care, housing or food can decrease one’s chances for green card approval and another 16% incorrectly believe this to be the case. Among immigrants who are likely undocumented, nine in ten are either unsure (68%) or incorrectly believe use of these types of public programs will decrease their chances for green card approval (22%).

What Are Immigrants Plans And Hopes For The Future?

Six in ten immigrants say they plan to stay in the U.S. However, about one in five immigrants say they want to move back to the country they were born in (12%) or to another country (7%), and about one in five (21%) say they are not sure. The desire to stay in the U.S. varies by immigration status as well as by race and ethnicity. Nearly two in three immigrants who are naturalized citizens say they plan to stay in the country, compared to about half of immigrants who have a green card or valid visa (54%) or immigrants who are likely undocumented (52%). Black immigrants are somewhat more likely than immigrants from other racial or ethnic backgrounds to say they plan to leave the U.S. (28%). This includes 17% who say they want to move back to their country of birth and 11% who say they want to move to a different country.

Three in four immigrants say they would choose to come to the U.S. again. Asked what they would do if given the chance to go back in time knowing what they know now, three in four immigrants (75%) say they would choose to come to the U.S. again, including large shares across ages, educational attainment, income, immigration status, and race and ethnicity. While most immigrants share this sentiment, overall, about one in ten (8%) immigrants say they would not choose to move to the U.S. and about one in five (17%) say they are not sure whether they would choose to move to the U.S.

Conclusion

Immigrants represent a significant and growing share of the U.S. population, contributing to their communities and to the nation’s culture and economy. Immigrants come to the U.S. largely seeking better opportunities and lives for themselves and their children, often leaving impoverished and sometimes dangerous conditions in their country of birth. For many, this dream has been realized despite ongoing challenges they face in the U.S.

Many immigrants recognize work as a key element to achieving their goals and are willing to fill physically demanding, lower paid jobs, for which some feel they are overqualified. Immigrants are disproportionately employed in agricultural, construction, and service jobs that are often essential for our nation’s infrastructure and operations.

Despite high rates of employment and, for many, an improved situation relative to their county of birth, many immigrants face serious challenges in the U.S. Finances are a top challenge and concern, with many having difficulty making ends meet and paying for basic needs. Moreover, although most immigrants feel welcome in their neighborhood, many face discrimination and unfair treatment on the job, in their communities, and while seeking health care. Fears of detention and deportation are a concern for immigrants across immigration statuses, sometimes affecting daily lives and interactions, particularly among those who are likely undocumented.

Some immigrants face more challenges than others, reflecting the diversity of the immigrant experience and the compounding impacts of intersectional factors such as immigration status, race and ethnicity, and income. Black and Hispanic immigrants, likely undocumented immigrants, immigrants with limited English proficiency, and lower income immigrants face disproportionate challenges given the impacts of racism, fears and uncertainties related to immigration status, language barriers, and financial challenges. Many immigrants lack sufficient information to understand how U.S. immigration laws and policies impact them and their families. This confusion and lack of certainty contributes to some immigrants avoiding accessing assistance programs that could ease financial challenges and facilitate access to health care for themselves and their children, who are often U.S.-born.

As the immigrant population in the U.S. continues to grow, recognizing their contributions and challenges of immigrants and addressing their diverse needs will be important for improving the nation’s overall health and economic prosperity.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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. Supplemental 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 – July 9, 2023). ↩︎
2. The estimate of the total number of noncitizens in the US is based on the 2021 American Community Survey (ACS) 1-year Public Use Microdata Sample (PUMS). The ACS data do not directly indicate whether an immigrant is lawfully present or not. We draw on the methods underlying the 2013 analysis by the State Health Access Data Assistance Center (SHADAC) and the recommendations made by Van Hook et. al.1,2 This approach uses the Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status; it then applies the model to ACS, controlling to state-level estimates of total undocumented population from Pew Research Center. For more detail on the immigration imputation used in this analysis, see the Technical Appendix B. ↩︎