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. ↩︎

Note: This content was updated on February 14, 2024 to correct the description of how states were classified in terms of expansiveness of coverage for immigrants.

Executive Summary

Immigrant adults are a diverse population who make up 16% of adults in the United States and play a significant role in the nation’s workforce and communities, with one in four children in the U.S. having at least one immigrant parent (see Box 1). Immigrants include individuals with varied citizenship and immigration statuses, countries of origin, racial and ethnic identities, and social and economic circumstances. Yet, this diversity among immigrants is not always reflected in policy debates or discussions. While some data are available on health and health care for immigrants, they provide limited understanding of the variation of experiences among immigrants by different factors, particularly immigration status (see Box 2), which is not collected in federal surveys.

This report provides new data on health and health care experiences of immigrant adults ages 18 and over in the U.S., including data by immigration status, income, race and ethnicity, and other factors.¹  It is based on the Survey of Immigrants, the largest and most representative nongovernmental survey of immigrants living in the U.S. to date, which was conducted by KFF in partnership with the Los Angeles Times during Spring 2023. The survey allows for a much richer and more nuanced understanding of the diversity of immigrant experiences and provides broader insights into experiences in health care settings than previously available through other data sources. KFF also conducted focus groups with immigrants from an array of backgrounds, which expand upon the survey information (see Methodology for more details). The report includes some data for the U.S.-born adult population based on a survey of the overall adult population conducted as part of this project and, in some other cases, federal survey data.

As shown in a companion report, although most immigrants say they came to the U.S. seeking better opportunities for themselves and their children and that their situations are improved relative to their countries of birth, many report facing serious challenges. This report further shows how these challenges extend to health care. Although most immigrants are healthy and employed, many face challenges to accessing and using health care in the U.S. due to higher uninsured rates, affordability challenges, linguistic and cultural barriers, and immigration-related fears, which has negative implications for their health and financial security. These challenges are more pronounced for some immigrants, including those who are likely undocumented, who have lower incomes, who are Black and Hispanic, and who have limited English proficiency (LEP). The survey data also show the difficulties immigrants face in obtaining health coverage and underscore the major role that coverage plays in access to health care. Although most immigrants are employed, they often are in lower wage jobs and industries that are less likely to offer health coverage, leading to lower rates of private coverage and higher uninsured rates. Noncitizen immigrants also face restrictions on eligibility for federally funded coverage. Given these restrictions, state coverage policies make a difference as immigrant adults in states that have adopted more expansive coverage policies are less likely to be uninsured. Consistent with the overall uninsured population, uninsured immigrants report significantly larger barriers to accessing and utilizing care compared to their insured counterparts. Some immigrants, particularly Black, Hispanic, and Asian immigrants have also experienced unfair treatment when seeking health care and difficulty accessing respectful and culturally competent care.

Key takeaways from this report include the following:

• Most immigrant adults (79%) report being in excellent or good health, but lower income immigrant adults are more likely to report worse health and having health conditions. Although most immigrant adults report good to excellent health, 14% say they have a health condition that requires ongoing treatment. Income is highly associated with self-reported health status, with worse health status and higher rates of health conditions reported among those with lower incomes. Nearly one in three (31%) lower income immigrant adults (household incomes of less than $40,000 per year) report fair or poor health compared with 7% of those in households with annual incomes of at least $90,000.
• Half of likely undocumented immigrant adults and nearly one in five (18%) lawfully present immigrant adults report being uninsured compared with less than one in ten citizens. Coverage rates also vary by income, with a quarter (24%) of lower income immigrant adults reporting being uninsured compared with 5% of immigrant adults with household incomes of at least $90,000. The high uninsured rates among noncitizen and lower income immigrant adults primarily reflect lower levels of private coverage due to disproportionate employment in lower income jobs that are less likely to offer employer-based insurance. Medicaid coverage helps offset some, but not all, of this gap, as many noncitizen immigrants remain ineligible for federally funded coverage programs. Many lawfully present immigrants face a five-year waiting period to enroll in Medicaid or Children’s Health Insurance Program (CHIP) coverage, and undocumented immigrants are prohibited from enrolling in any federally funded coverage, including Medicaid, CHIP, Affordable Care Act (ACA) Marketplace, and Medicare coverage.
• While immigration status is a primary factor driving differences in uninsured rates, where immigrants live also matters, as those residing in states that provide more expansive coverage are less likely to be uninsured. States vary in the coverage they provide for their low-income population overall and immigrants specifically. Those that have adopted the ACA Medicaid expansion have broader eligibility for low-income adults, but noncitizen immigrants still face eligibility restrictions for this coverage. Some states have expanded coverage for immigrants by eliminating the five-year waiting period in Medicaid and/or CHIP for children and/or pregnant people and/or extending coverage to some groups regardless of immigration status through fully state-funded programs. Immigrants in states that have taken up more of these coverage options are less likely to be uninsured. For example, the uninsured rate for immigrant adults in California is less than one-third what it is in Texas (8% vs. 27%), reflecting more expansive coverage in California. Overall, immigrant adults in states with more expansive coverage, including Medicaid expansion and immigrant coverage expansions, are half as likely as immigrant adults residing in states with less expansive coverage to be uninsured (11% vs. 22%).
• While most immigrant adults report seeking or obtaining health care in the U.S. (84%) and say they have had a health care visit in the past year (77%), about half (48%) of uninsured immigrant adults report a visit in the past year. Hispanic and Black immigrants, likely undocumented immigrants, and those with LEP also are less likely to say have sought health care since arriving in the U.S. and less likely to report receiving health care in the past year. While this pattern largely reflects higher uninsured rates among these groups, some differences persist among those who have coverage, suggesting other factors such as immigration-related fears and linguistic barriers may also reduce use of care. Private doctors’ offices are the most common regular source of care for immigrant adults but nearly one in three say they use a community health center (CHC) or clinic.
• Among immigrant adults who have received care in the U.S., one in four (25%) reports being treated unfairly by a health care provider because of their insurance status or ability to pay (16%); accent or ability to speak English (15%); and/or their race, ethnicity, or skin color (13%). Black immigrant adults are more than twice as likely as White immigrant adults to report being treated unfairly for at least one of these reasons (38% vs. 18%), and the share is also higher among Hispanic immigrant adults (28%). Black, Asian, and Hispanic immigrant adults are all more likely than their White counterparts to say they have been treated differently by a health care provider because of their race, ethnicity, or skin color as well as due to their accent or ability to speak English, with one in four (25%) of Black immigrants saying they were treated unfairly based on their race, ethnicity, or skin color.
• About three in ten (29%) immigrant adults who have sought care in the U.S. report experiencing at least one of several difficulties obtaining respectful and culturally competent care asked about on the survey. These difficulties include a provider not taking the time to listen or ignoring concerns (17%); a provider not explaining things in a way they could understand (15%); being treated with disrespect by front office staff (12%); and, among those with LEP who completed the survey in a non-English language, interpretation services not available or provided in a timely manner (17%). The shares reporting any of these difficulties are higher among Black (34%), Hispanic (33%), uninsured (39%), and likely undocumented (34%) immigrant adults and those with lower household incomes compared with their White, insured, citizen, and higher income counterparts.
• One in five (20%) immigrant adults reports problems paying for health care in the past year and a similar share (22%) say they skipped or postponed care in the past year, with these shares rising to about a third (36%) among those who are uninsured. About seven in ten (69%) of those who skipped or postponed care (15% of all immigrant adults) say they did so due to cost or lack of health coverage, and about half (49%) (10% of all immigrant adults) say they did so because of services not being available at a convenient time or location. Smaller shares say it was because they didn’t know where to go or how to find the services they needed, or, among those with LEP, not being able to speak to someone in their preferred language or get an interpreter. Overall, 40% of immigrant adults who skipped or postponed care (9% of all immigrant adults) say that their health got worse as a result of skipping or postponing care.
• Many immigrant adults are uncertain about how using assistance for food, housing, and health care may impact their immigration status, and some are fearful of applying for this assistance. Given lower incomes among immigrant families and difficulties paying for basic needs and monthly bills, food, housing, and health care assistance programs could reduce financial stress and facilitate access to care for them and their children. Although many noncitizen immigrants are ineligible for these programs, children in immigrant families are often U.S.-born citizens who may be eligible. However, nearly three-quarters of immigrant adults, including nine in ten of those who are likely undocumented, report uncertainty about how use of these programs may impact immigration status or incorrectly believe use may reduce the chances of getting a green card in the future. About a quarter (27%) of likely undocumented immigrants and nearly one in ten (8%) lawfully present immigrants say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears. Partly reflecting this fear as well as language barriers and eligibility restrictions, immigrant adults are no more likely than their U.S.-born counterparts to say they or someone living with them received government assistance with food, housing, or health care despite having lower incomes and facing financial challenges, with 28% of both groups reporting receiving assistance in the past year.² 

Immigrant Health and Well-being

Most immigrant adults say they are in good to excellent health. Overall, close to eight in ten (79%) immigrant adults report they are in excellent, very good, or good health, while 21% report being in fair or poor health. Roughly eight in ten of the overall U.S. adult population also reports being in excellent, very good, or good health.⁴  Income is highly associated with self-reported health status as nearly one in three (31%) lower income immigrant adults (household incomes of less than $40,000 per year) report fair or poor health compared with just 7% of those in households with annual income of at least $90,000 (Figure 1). Largely reflecting these income differences, among immigrant adults, those who are Hispanic and are likely undocumented are disproportionately likely to report fair or poor health.

Overall, 14% percent of immigrant adults say they have a health condition that requires ongoing treatment. Consistent with patterns of self-reported health status, nearly one in five (19%) of those with household incomes below $40,000 per year report a health condition that requires ongoing treatment, compared to about one in ten of those with higher incomes.

Health Coverage of Immigrants

Health insurance coverage makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately how healthy they are. Overall, uninsured people are far more likely than those with insurance to not have a usual source of care, to not have had a health care visit in the past year, and to postpone or forgo health care due to cost. Postponed or forgone care can lead to preventable conditions or chronic diseases going undetected and worsening conditions. In addition, for many uninsured people, health care costs create financial stress and can lead to debt as well as difficult choices between health care costs and paying for other needs, like housing, food, and transportation.

Fifteen percent of immigrant adults 18 and older and nearly one in five (18%) nonelderly adult immigrants (ages 18-64) report being uninsured (Figure 2). In comparison, 8% of U.S.-born adults and 11% of U.S.-born nonelderly adults (ages 18-64) say they lack coverage.⁵  These higher uninsured rates primarily reflect lower levels of private coverage compared to their U.S.-born counterparts. Medicaid coverage helps offset some but not all of this gap, resulting in higher uninsured rates.

Although most immigrant adults are working, many are employed in lower income jobs and industries that are less likely to offer employer-sponsored insurance, contributing to lower rates of private coverage. Among nonelderly immigrant adults (18-64 years) employed for pay, half (50%) report having employer-sponsored coverage through themselves or a family member. The rate of employer-sponsored coverage is higher among salaried employees (74%) compared with four in ten (43%) of those who are paid hourly and just one in five (18%) who are paid by the job. Reflecting these differences, just 6% of salaried nonelderly immigrant workers say they are uninsured compared with 20% of those who are paid hourly and 38% who are paid by the job.

Although Medicaid coverage helps fill some of the gap in private coverage for immigrant adults, many noncitizen immigrants are subject to eligibility restrictions for federally funded health coverage programs. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or the Children’s Health Insurance Program (CHIP), and many must wait five years after obtaining qualified status before they may enroll. States can eliminate the five-year waiting period for children and pregnant people. Lawfully present immigrants can purchase ACA Marketplace coverage without a waiting period. Lawfully present immigrants also can qualify for Medicare if they have sufficient work history or if they are lawful permanent residents and have resided in the U.S. for five years immediately prior to enrolling in Medicare, although those without sufficient work history must pay premiums to enroll in Part A. Undocumented immigrants are not eligible to enroll in any federally funded coverage. A small number of states have extended health coverage to some low-income immigrants regardless of immigration status using state-only funds. Even when eligible for coverage, immigrants may face challenges to enrolling due to language barriers or immigration-related fears.

Reflecting more limited access to coverage, half of likely undocumented immigrant adults (50%) and nearly one in five lawfully present immigrant adults (18%) report being uninsured compared with 6% of naturalized citizens (Figure 3). Moreover, roughly one in four (24%) lower income immigrant adults reports being uninsured compared to just 5% of those with annual incomes of $90,000 or more. Having LEP also is associated with a higher uninsured rate, with one in five (21%) immigrant adults with LEP saying they are uninsured compared with one in ten immigrant adults who are English proficient. In addition to including larger shares of noncitizen immigrants, people with LEP may face linguistic barriers to enrolling in coverage when they are eligible.

Hispanic immigrant adults are more than three times as likely as White immigrant adults to be uninsured (Figure 3). About one in four (26%) Hispanic immigrant adults report being uninsured compared with roughly one in ten of Black immigrant adults (10%) and White immigrant adults (8%), and just 4% of Asian immigrant adults. While some of these differences reflect lower incomes and higher rates of noncitizens among Hispanic immigrant adults, Hispanic immigrant adults in higher income households (14%) or who are naturalized citizens (10%) are still more likely than their White higher income (3%) and naturalized citizen (3%) counterparts to be uninsured, suggesting they face additional barriers to coverage, such as language or cultural barriers. There is no significant difference in uninsured rates by gender among immigrant adults, which may reflect immigrant eligibility restrictions for Medicaid. Among the overall U.S. adult nonelderly population, women have a lower uninsured rate than men due to higher Medicaid coverage rates.

Uninsured rates among immigrants also vary based on where they live, as immigrant adults in states that have expanded Medicaid to low-income adults and expanded coverage for immigrants are less likely to report being uninsured. States vary in the coverage they provide for their low-income population overall as well as immigrants specifically. Those that have adopted the ACA Medicaid expansion have broader eligibility for low-income adults overall, but noncitizen immigrants still face eligibility restrictions for this coverage. Some states have expanded coverage for immigrants by eliminating the five-year waiting period in Medicaid and/or CHIP for children and/or pregnant people and/or extending coverage to some immigrants regardless of immigration status through fully state-funded programs. Immigrants in states that have taken up more of these coverage options are less likely to be uninsured. For example, the uninsured rate for immigrant adults in California is less than one-third what it is in Texas (8% vs. 27%) (Figure 4). California has adopted the ACA Medicaid expansion to low-income adults, expanded coverage for recent lawfully present immigrant children and pregnant people in Medicaid and CHIP, and began providing fully state-funded coverage regardless of immigration status to children in 2016 and to some adults in 2019. In contrast, in Texas, Medicaid eligibility for adults remains limited to very low-income parents (16% of the federal poverty level or about $4,000 per year for a family of three), and the state does not provide any state-funded coverage for immigrants. When looking at coverage patterns across states overall, immigrant adults who live in states that provide more expansive coverage for immigrants, including Medicaid expansion and immigrant coverage expansions, are half as likely to be uninsured compared with those living in states with less expansive policies (11% vs. 22%) (see Box 3).

Immigrants’ Use of Health Care in the U.S.

A large majority (84%) of immigrant adults report they have received or tried to receive medical care in the U.S., and most say they saw a health care provider in the past year (77%) (Figure 5). Roughly eight in ten of U.S.-born adults also say they had a health care visit in the past year.⁶  For many immigrants, seeking and obtaining health care in the U.S. requires learning how to navigate a new health care system that differs from the system in their country of birth, which can present challenges. Aside from financial and logistical challenges to accessing care (discussed below), prior experiences in their country of birth and/or cultural differences may also affect use of and experiences with care in the U.S.

Consistent with patterns among the overall uninsured population, uninsured immigrant adults are less likely than those with coverage to say they have sought or obtained health care in the U.S. Reflecting the important role health coverage plays in facilitating access to care, across coverage types, roughly nine in ten (88%) of immigrant adults with coverage report seeking or using care in the U.S. compared with about seven in ten (68%) uninsured immigrant adults (Figure 5). About half (48%) of uninsured immigrant adults say they had a health care visit in the past year compared with about eight in ten of insured immigrant adults (82%). Among U.S.-born adults, those who are uninsured also are much less likely than those with coverage to have a had health care visit in the past year.⁷  Although majorities across groups say they have sought or received care in the U.S., the shares of Black and Hispanic immigrant adults saying this are lower than for White immigrants. While this pattern, in part, reflects differences in coverage, these racial differences persist among those who are insured. Noncitizen immigrants, particularly those who are likely undocumented, and those with LEP also are less likely to say they have sought or received health care compared with naturalized citizens and those who speak English very well. In addition to higher uninsured rates among these groups, immigration-related fears and linguistic barriers may also reduce use of care.

Consistent with experiences among the overall adult population⁸ , most (79%) immigrant adults say they have a usual source of care other than a hospital emergency room, but the share is much lower among uninsured immigrant adults (56%) (Figure 6). Among insured immigrant adults, those with Medicare coverage are the most likely to report having a usual source of care (88%).

About seven in ten immigrant adults say they go to a private doctor’s office (43%) or community health clinic (CHC) (30%) when they are sick or need health advice, but nearly one in five (17%) say they do not have a place other than an emergency room (Figure 6). CHCs are a national network of safety-net primary care providers serving low-income and medically underserved communities, including communities of color, uninsured people, immigrants, and those in rural areas. Research shows that CHCs offer linguistically and culturally competent care to underserved racial and ethnic groups as well as people with LEP and that these services can positively impact patient satisfaction. Reflecting this role, uninsured immigrant adults (37%) and those covered by Medicaid (44%) are more likely to say a CHC is their usual source of care than those with private (26%) or Medicare (24%) coverage. CHCs also serve as a usual source of care for large shares of immigrant adults who are Hispanic (41%), are likely undocumented (42%), have LEP (39%), and are lower income (37%). Even among those with health coverage, Hispanic immigrants and those with LEP are more likely to say a CHC is their usual source of care than their White and Asian counterparts and those who are English proficient.

Immigrants’ Experiences Receiving Health Care in the U.S.

Overall, the majority of immigrant adults say they have a trusted doctor or health care provider in the U.S., but this share falls to 32% among those who are uninsured (Figure 7). About three-quarters (74%) of immigrant adults report having a doctor or other medical provider in the U.S. who they trust to answer questions about their health. This is lower than the share of U.S.-born adults (83%) who say they have a trusted health care provider.⁹  The share of immigrant adults saying they have a trusted health care provider falls to about one in three (32%) among uninsured immigrant adults compared to about eight in ten of those who are insured. Across coverage types, most insured immigrant adults say they have a trusted doctor, with the share highest among those with Medicare coverage (91%). Given that noncitizen (particularly likely undocumented), Hispanic and lower income immigrants as well as immigrants with LEP have higher uninsured rates, these groups also are less likely to report having a trusted doctor than naturalized citizens, other racial and ethnic groups, those with higher incomes, and those that speak English very well. However, even among adults with private coverage, immigrants with LEP (75%) remain less likely than their English proficient peers (83%) to say they have a trusted doctor.

Among those who received care in the U.S., one in four (25%) immigrant adults reports being treated unfairly by a health care provider based on one of several factors asked about, with Black and Hispanic immigrant adults reporting higher rates of unfair treatment (Figure 8). Overall, 25% of immigrant adults who have received care in the U.S. say they have been treated differently or unfairly by a doctor or other health care provider because of their insurance status or ability to pay (16%); accent or ability to speak English (15%); and/or their race, ethnicity, or skin color (13%). Black immigrant adults are about twice as likely as White immigrant adults to report being treated unfairly for at least one of these reasons (38% vs. 18%), and the share is also high among Hispanic (28%) immigrant adults. Black, Asian, and Hispanic immigrant adults are all more likely than their White counterparts to say they have been treated differently by a health care provider because of their race, ethnicity, or skin color as well as due to their accent or ability to speak English, with one in four (25%) of Black immigrants saying they were treated unfairly based on their race, ethnicity, or skin color. Black immigrant adults also are more likely than their White counterparts say they were treated differently due to their insurance status or ability to pay (23% vs. 14%). In addition, larger shares of immigrants who are uninsured (34%), lower income (31%), and who have LEP (28%) say they have been treated unfairly in at least one of these ways compared with their insured, higher income, and English proficient counterparts.

About three in ten (29%) immigrant adults who have sought care in the U.S. report one of several difficulties obtaining respectful and culturally competent care asked about on the survey (Figure 9) These challenges include a provider not taking the time to listen or ignoring concerns (17%); a health care provider not explaining things in a way they could understand (15%); being treated with disrespect by front office staff (12%); and, among those with LEP who completed the survey in a non-English language, interpretation services not available or provided in a timely manner (17%). The shares reporting any difficulties obtaining respectful and culturally competent care are particularly high among Black (34%), Hispanic (33%), uninsured (39%), and likely undocumented (34%) immigrant adults and those with household incomes below $90,000. In particular, about one in four Black (24%) and uninsured (24%) immigrant adults say a provider did not take the time to listen to or ignored their concerns, and about one in five likely undocumented immigrant adults (21%) and immigrant adults with LEP (18%) a say a health care provider did not explain things in a way they could understand. Women are also more likely than men to report experiencing at least one of these challenges (31% vs. 25%).

Challenges Accessing Health Care Among Immigrants

One in five (20%) immigrant adults, rising to nearly four in ten (38%) among those who are uninsured, report they or someone they live with had problems paying for health care in the past 12 months (Figure 10). The shares reporting problems are also higher among lower income immigrant adults compared with their higher income counterparts. Black and Hispanic and noncitizen immigrant adults are more likely than their White and naturalized citizen peers to report problems paying for care, reflecting higher uninsured rates and lower incomes among these groups. Beyond cost, some also point to problems accessing care due to language barriers. Nearly one in three (31%) of immigrant adults with LEP say they have ever had difficulty getting health care services because of difficulty speaking or understanding English.

Overall, about one in five (22%) immigrant adults report they skipped or postponed health care for any reason in the past 12 months (Figure 11). The share skipping or going without care rises to 36% among uninsured immigrant adults. Lower income and likely undocumented immigrant adults also are more likely to say they skipped or went without care compared with their higher income and naturalized citizen or lawfully present immigrant counterparts. Overall, 9% of immigrant adults (representing 40% of those who skipped or postponed care) say that their health got worse as a result of skipping or postponing care. The share saying their health got worse rises to one in five (19%) of uninsured immigrant adults and 14% of likely undocumented immigrant adults.

About seven in ten (69%) of immigrant adults who skipped or postponed care in the past year (15% of all immigrant adults) say they did so due to cost or lack of health coverage (Figure 12). Among uninsured immigrant adults, nearly all (95%) of those who skipped or postponed care (34% of all uninsured immigrant adults) cite this as a reason. About half (49%) of immigrant adults who skipped or postponed care (10% of all immigrant adults) say they did so because of services not being available at a convenient time or location, nearly four in ten (39%) (8% of all immigrant adults) say they didn’t know where to go or how to find the services they needed, and, among those with LEP who skipped or postponed care, a quarter (25%) (1% of all immigrant adults with LEP) cited not being able to speak to someone in their preferred language or get an interpreter.

Health Coverage and Care Among Children of Immigrants

Children in immigrant families are often U.S.-born citizens who are not subject to immigrant eligibility restrictions for federally funded health coverage and other assistance programs. Medicaid and CHIP also provide more expansive income eligibility limits for children compared to parents and other adults, contributing to lower uninsured rates for children overall. As such, children in immigrant families may have broader eligibility for coverage than their parents. However, even when their children are eligible for coverage, many immigrant parents may still face barriers to enrolling them in coverage, including lack of information or confusion about eligibility rules, immigration-related fears, and/or language barriers.

About one in ten (9%) of immigrant parents say at least one child in their household is uninsured (Figure 13). Immigrant parents who have lower incomes, are noncitizens, and have LEP are particularly likely to say at least one child is uninsured. Given that Hispanic immigrant parents are more likely to have lower income, be noncitizens, and have LEP, they are more likely than their White counterparts to report having at least one uninsured child (15% vs. 2%). Reflecting that Medicaid and CHIP offer comprehensive coverage to low-income children across states, about four in ten (41%) immigrant parents say they are lower income (household income of less than $40,000 a year), and many children of immigrants are U.S.-born citizens who are not subject to immigrant eligibility restrictions, nearly half (49%) of immigrant parents say they have at least one child covered by Medicaid or CHIP, including three in four (75%) who are lower income.

Most immigrant parents (83%) say at least one of their children has received a well-child visit in the past 12 months (Figure 14). There were no significant differences in the share of immigrant parents reporting their child had a check-up in the past year by race and ethnicity, income, or immigration status. However, reinforcing the importance of coverage for facilitating access to care, immigrant parents who have an uninsured child are less likely than those who have a child who is covered by Medicaid or CHIP to say their child received a well-visit in the past 12 months (72% vs. 87%). Beyond coverage, linguistic barriers can also impede access. Immigrant parents with LEP are less likely than those who are English proficient to say their children received a check-up in the past year (78% vs. 89%).

About one in ten immigrant parents say any of their children delayed or skipped health care (7%) or dental care (10%) in the past 12 months due to lack of insurance or cost. Immigrant parents who have an uninsured child are four times more likely than those who have a child covered by Medicaid or CHIP to report that any of their children delayed or skipped health care (32% vs. 8%) or dental care (41% vs. 9%) due to lack of coverage or cost.

Use of Public Assistance and Public Charge Fears

Food, housing, and health care assistance programs could reduce financial stress and facilitate access to health care among immigrant families, but many report confusion or concerns about using these programs. 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. However, this policy was rescinded by the Biden Administration in 2021, meaning that the use of assistance for health care, food, and housing is not considered for public charge tests, except for long-term institutionalization at government expense. The Biden Administration also has reiterated and clarified that use of these programs by U.S.-born citizen children in immigrant families is not considered in public charge determinations. Although many noncitizen immigrants are ineligible for these programs, their children are often U.S.-born citizens who may be eligible. However, the survey reveals that many immigrants remain confused about public charge rules. About 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 (Figure 15). Among immigrants who are likely undocumented, nine in ten are either unsure (68%) or incorrectly believe (22%) use of these types of programs will decrease chances for green card approval. A higher share of immigrant adults with LEP also report uncertainty or an incorrect understanding about these rules compared with those who are English proficient (79% vs. 70%).

About one in four (27%) likely undocumented immigrants say they have avoided applying for government assistance with food, housing, or health care in the past year due to immigration-related fears (Figure 16). These fears are not limited to likely undocumented immigrants with roughly one in ten (8%) of lawfully present immigrants also saying they avoided applying for this assistance in the past year. Some also report linguistic barriers to accessing assistance. Among immigrant adults with LEP, a quarter (25%) say they had difficulty applying for government help with food, housing, or health coverage because of difficulty speaking or understanding English, and this share rises to 31% among lower income immigrant adults with LEP.

Reflecting this uncertainty and fear as well as language barriers and eligibility restrictions, immigrant adults are no more likely than U.S.-born adults to say they or someone living with them received government assistance with food, housing, or health care in the past year despite having lower household incomes and facing financial difficulties. Overall, 28% of immigrant adults said they or someone living with them received government assistance with food, housing, or health care in the past 12 months, the same share as U.S.-born adults (28%) (Figure 17).¹⁰  This share rises to 45% of lower income immigrant adults and is also high among immigrant adults who are parents (38%), are Hispanic (37%), are likely undocumented (37%), and have LEP (36%). In many cases, this assistance is likely going to citizen children in these families, given that lawfully present immigrants face eligibility restrictions for federally funded assistance programs and undocumented immigrants are prohibited from enrolling in them.

Conclusion

Despite the majority of immigrant adults in the U.S. being employed and in good health and reporting generally improved situations as a result of moving to the country, many face barriers to accessing health coverage and health care. Access to health coverage and care varies significantly across immigrants, with some groups facing larger challenges, including those who are likely undocumented, who have lower incomes, who are Black and Hispanic, and who have LEP. The survey data also underscore the major role that coverage plays in access to health care, as, consistent with the overall uninsured population, uninsured immigrants report significantly larger barriers to accessing and utilizing care compared to their insured counterparts.

Half of likely undocumented immigrant adults and nearly one in five lawfully present immigrant adults say they are uninsured, reflecting lower rates of private coverage and eligibility restrictions on federally funded coverage for many noncitizen immigrants. The survey data show that availability of public coverage options for immigrants makes a difference in their coverage rates, with lower uninsured rates among immigrant adults in states that have adopted more expansive coverage policies. The survey data also point to other barriers to coverage, including immigration-related fears and language barriers. Coverage gaps among immigrants may grow as they may be at particular risk for coverage losses amid the unwinding of the Medicaid continuous enrollment provision established during the COVID-19 public health emergency due to potential language barriers and/or lack of information or confusion around eligibility rules.

The data further underscore the major role that coverage plays in immigrant adults’ ability to access health care. Consistent with trends in the overall population, compared to their insured counterparts, uninsured immigrant adults are less likely to receive health care, to have a regular source of care aside from an emergency room, and to have a trusted doctor. They also are more likely to report problems paying for health care in the past year, to say they skipped or postponed care, and to say that their health got worse as a result of going without or delaying care. Some groups of immigrant adults, including Hispanic and Black immigrants, lower income immigrants, likely undocumented immigrants, and immigrants with LEP also are more likely to experience these challenges, largely reflecting higher uninsured rates among these groups. However, in some cases, differences persist even among those with coverage.

Among immigrants who have used health care in the U.S., some report experiencing differential or unfair treatment and challenges accessing respectful and culturally competent care. A quarter of immigrant adults report being treated differently or unfairly by a health care provider, with particularly high shares of immigrant adults who are Black, Hispanic, likely undocumented, and have LEP reporting unfair treatment. About three in ten immigrant adults report one of several difficulties obtaining respectful and culturally competent care including a provider not taking the time to listen or ignoring concerns; a health care provider not explaining things in a way you could understand; being treated with disrespect by front office staff; and, among those with LEP, interpretation services not available or provided in a timely manner. The shares reporting any difficulties obtaining respectful and culturally competent care are particularly high among Black, Hispanic, uninsured, and likely undocumented immigrant adults and those with lower household incomes.

Given lower incomes among immigrant families and difficulties paying for basic needs such as monthly bills, food, housing, and health care assistance programs could reduce financial stress and facilitate access to care for them and their children. Although many noncitizen immigrants remain ineligible for these programs, their children are often U.S.-born citizens who may be eligible. However, the majority of immigrant adults across immigration statuses report uncertainty about how use of these programs may impact immigration status or incorrectly believe use may negatively affect the chances of getting a green card in this future. About a quarter of likely undocumented immigrants say they avoided applying for assistance for food, housing, or health in the past year due to immigration-related fears. Partly reflecting this fear as well as language barriers and eligibility restrictions, immigrant adults are no more likely than their U.S.-born counterparts to say they or someone living with them received government assistance with food, housing, or health care despite having lower incomes and facing financial challenges.

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. All differences described in the text are statistically significant at p<0.05 unless otherwise noted. ↩︎
2. 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). ↩︎
3. 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. ↩︎
4. KFF analysis of 2021 Behavioral Risk Factors Surveillance System (BRFSS) data. ↩︎
5. KFF/LA Times Survey of Immigrants: U.S. Born Adult Comparison (June 29 – July 9, 2023). ↩︎
6. KFF analysis of 2022 National Health Interview Survey (NHIS) adult interview sample. ↩︎
7. KFF analysis of 2022 National Health Interview Survey (NHIS) adult interview sample. ↩︎
8. KFF analysis of 2022 National Health Interview Survey (NHIS) adult interview sample. ↩︎
9. KFF/LA Times Survey of Immigrants: U.S. Born Adult Comparison (June 29-July 9, 2023). ↩︎
10. KFF/LA Times Survey of Immigrants: U.S. Born Adult Comparison (June 29-July 9, 2023). ↩︎

Why Rural Adults?

Understanding beliefs, attitudes, and information gaps that may be associated with health behaviors and decisions can provide important insights for those working to promote positive health outcomes in different communities. Adults in rural communities are more likely to be older, White, and have lower levels of educational attainment than U.S. adults in suburban and urban communities. Additionally, rural adults are more likely to identify with the Republican party than urban adults. The KFF Health Misinformation Tracking Poll Pilot has found that each of these indicators is correlated with being more likely to say that items of health misinformation items in this survey are “definitely” or “probably true.” Previously, the KFF COVID-19 Vaccine Monitor consistently found that U.S. adults in rural areas were less likely than those living in urban or suburban areas to say they were vaccinated or intended to get vaccinated against COVID-19. Other studies found that, on the county level, lower rates of COVID-19 vaccinations were associated with capacity problems at rural hospitals. Understanding and addressing information needs in rural communities is one component of promoting public health and hopefully improving outcomes in future public health emergencies.

Key Takeaways for the Field

• Large shares of adults in rural communities in the U.S. have been exposed to pieces of health information, but most are not completely bought in. A majority of rural adults say that each of the items of misinformation surveyed are “probably true” or “probably false.” Few – about one in five or fewer – say that any item is “definitely true.” On the other hand, across all items, about one-third or fewer correctly say that each is “definitely false.” With many rural adults landing in the “muddled middle” – believing the items were either “probably true” or “probably false” – there is an opportunity to address information gaps through channels that adults in rural communities regularly seek out or trust most.
• Addressing misinformation about gun violence among rural residents is of particular importance given high rates of gun ownership in rural communities. A majority of rural residents say they or someone in their household is a gun owner compared to about three in ten urban residents. Rural residents are also more likely than their urban counterparts to say the false claim that “armed school police guards have been proven to prevent school shootings” (73% among rural adults v. 56% among urban residents) and the claim that “people who have a firearm in their home are less likely to be killed by a gun than those who do not have a firearm” are definitely or probably true (50% vs. 40%). Rural gun owners and those who live in households with gun owners stand out when compared their counterparts in suburban and urban areas as being most likely to say that it is true that “people who have a firearm in their home are less likely to be killed by a gun than those who do not have a firearm” are definitely or probably true.
• Local news sources may be particularly well-positioned to address health misinformation among rural residents. Among the news sources included in the survey, rural adults are most likely to report regularly watching their local TV news station and national news networks to keep up-to-date. Half of adults living in rural areas also say they read their local newspapers regularly, compared to about a third of suburban adults and four in ten urban adults. Along with being among the most frequently used sources, local TV news stations, local papers and national network news are also the most trusted traditional media sources of health information for rural communities.
• Rural adults are about ten percentage points less likely than urban adults to say they regularly use social media to keep up-to-date with the news or to access health advice or information. Nonetheless, though a large share of rural adults say they regularly use Facebook (72%) and YouTube (60%), only about four in ten say they would trust health information they came across on these platforms at least “a little,” with one in ten or fewer saying they would have “a lot” of trust.
• Similar to adults overall, doctors are key messengers of health issues with more than nine in ten adults in rural communities saying they trust their own doctor to give the right recommendations. Rural adults are much more trusting of their own doctor compared to government sources on health recommendations, though most rural residents say they have at least a fair amount of trust in the CDC, the FDA, and in their local public health officials. Only about a third express trust in the Biden Administration to make the right recommendation on health issues. As the beginnings of the 2024 Presidential election campaigns start to take shape, about half of rural residents have at least a fair amount of trust in former President Donald Trump to make the right recommendations on health issues.

Exposure to and Belief in Health Misinformation

While notable shares of rural adults are exposed to health-related misinformation, fewer are buying into specific false claims about COVID-19, reproductive health, and firearm violence and safety examined in the KFF Health Misinformation Tracking Poll Pilot. The survey first asks respondents if they have heard or read specific claims of health misinformation. Then, regardless of whether they have heard or read specific items of misinformation, the survey asks respondents whether they think each claim is definitely true, probably true, probably false, or definitely false.

Between four in ten and seven in ten rural adults have heard each of the items of health misinformation included in the survey. The most commonly heard items among rural adults are that “COVID-19 vaccines have caused thousands of sudden deaths in otherwise healthy people,” “the measles, mumps, rubella vaccines (MMR) have been proven to cause autism in children,” “armed school police guards have been proven to prevent school shootings,” and “most gun homicides in the U.S. are gang-related.”

When it comes to the verity of the statements, small shares of rural adults (fewer than 11%) say that false claims about COVID-19, vaccines, and reproductive health are “definitely true.” A slightly larger share, about two in ten, of rural adults say false claims related to firearms and gun safety are definitely true. However, between five percent and 35% reject these misinformation items as “definitely false.” Overall, most rural adults are in a larger middle group that express some uncertainty, saying these false claims are “probably true” or “probably false.”

For most of the misinformation items included in the survey, between one-quarter and half of rural adults say they are “definitely true” or “probably true,” while one item garners 73% of rural adults saying it is true (“Armed school police guards have been proven to prevent school shootings.”) Combining these measures, smaller shares of rural adults (between 18% and 44%) both have heard each claim and believe it is probably or definitely true.

Measures of Health Misinformation

This report examines three measures of health misinformation among the public. Adults were asked whether they had heard or read specific false health-related statements. Regardless of whether they have heard or read specific items of misinformation, all were asked whether they thought each claim was definitely true, probably true, probably false, or definitely false. We then combined these two measures in order to examine the share who have heard the false claims and believe it is definitely or probably true.

Most rural adults express uncertainty about the truthfulness of the false claims tested in the survey, with a majority saying each is either “probably true” or “probably false.” Small shares – about one-third or fewer – recognize any of the claims as “definitely false,” and about one in five or fewer say that any of these claims are “definitely true.”

Notably, nearly three-fourths of rural adults say that the false claim that “armed school police guards have been proven to prevent school shootings” is “definitely” or “probably true,” including one in five who say this is “definitely true.” Further, half of rural adults say it is probably or definitely true that “people who have firearms at home are less likely to be killed by a gun than people who do not have a firearm,” including one in five who say this is “definitely true.” Rural adults are more likely than urban adults to say both of these falsehoods are true, which may be related to the larger share of gun households in rural communities. The survey finds that a majority of rural adults say they or someone in their household is a gunowner (55%), compared to fewer suburbanites and urban residents (42% and 28% respectively).

Gun owners overall are more likely than those who do not own a gun to say each of the firearm-related pieces of misinformation are true, a finding consistent with studies showing that gun owners feel safer with a gun in their household than they would without it. However, even among gun owners and those who live in households with gun owners, those who live in rural areas stand out as being even more likely than those living in suburban and urban areas to believe that people who have firearms at home are less likely to be killed by a gun than people who do not have a firearm (two-thirds of rural adults in a gun-owning household say this is probably or definitely true, compared to fewer than half of urban and suburban adults in gun-owning households).

Media Consumption and Trust

Consumption of News, Social Media, and Health Information

A majority of rural adults say they regularly consume news from their local TV news station (59%) and national news networks such as ABC, CBS, or NBC (55%). Half say they read their local newspapers regularly, and 45% consume news from Fox News and digital news aggregators. Fewer regularly watch, listen to, or read MSNBC (35%), CNN (33%), NPR (26%), New York Times (18%), the Wall Street Journal (14%), Newsmax (12%) and OANN (6%).

The most used social media platforms among rural adults are Facebook and YouTube, with seven in ten and six in ten saying they use these platforms at least once per week respectively. Fewer use TikTok (33%), Instagram (28%), Snapchat (20%), Reddit (13%), Twitter (12%), or WhatsApp (6%) at least weekly. The distribution of social media platforms used in rural communities likely reflects the fact that they are older on average than urban or suburban communities.

When it comes to how rural adults engage with social media, half say they use social media at least once per week to keep up to date on news and current events. About one-fourth say they use social media for news and current events once a month or occasionally, and one in five say they never use social media for this purpose. A majority of rural adults say they use social media for health information and advice at least occasionally, though few (20%) use it this way at least once per week. Forty-five percent of rural adults say they “never” use social media for health advice.

Trust in Sources of Information

When it comes to sources of health recommendations, rural adults are at least twice as likely to trust their own doctors a great deal than the advice of government sources. More than half (56%) of rural adults say they trust their own doctor to make the right recommendations about health “a great deal” compared to about one in five or fewer who trust the recommendations from the CDC (21%), the FDA (17%) and their state and local public health officials (8%) “a great deal.” However, majorities trust each of these government sources at least “a fair amount.”

Reflecting the partisanship of adults in rural communities, rural adults are least trusting of the health recommendations from the Biden administration, with one-third (35%) of rural adults saying they trust the Biden administration, including just 8% who say they trust the Administration “a great deal.” An additional third (36%) say they do not trust the health recommendations from the Biden administration “at all.” Rural adults are split in their trust of former President Donald Trump’s recommendations, as one-fourth say they trust Trump to make the right recommendations when it comes to health issues “a great deal,” and a similar share (28%) say they do not trust him “at all.”

There are a range of news sources and platforms that rural adults find at least somewhat trustworthy when it comes to health information. A large majority say they would trust health information at least a little if it was reported by their local TV news, local newspaper, and network news. A smaller majority say they would trust information reported by digital or online news aggregators, Fox News, CNN, and MSNBC. Although fewer than three in ten say they would trust each of these sources “a lot,” this basis of trust can be used to address misinformation among rural communities.

One in ten or fewer say that they would have “a lot of trust” in information related to health reported on social media platforms.

This KFF Health Misinformation Tracking Poll Pilot was designed and analyzed by public opinion researchers at KFF. The survey was conducted May 23 – June 12, 2023, online and by telephone among a nationally representative sample of N=2,007 U.S. adults in English (1,881) and in Spanish (126). The sample includes 1,532 adults reached through the SSRS Opinion Panel either online or over the phone (n=78 in Spanish). The SSRS Opinion Panel is a nationally representative probability-based panel for which panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails. 1,445 panel members completed the survey online and panel members who do not use the internet were reached by phone (87).

Another 475 (n=48 in Spanish) interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Respondents in the prepaid phone samples received a $15 incentive by check received by mail, and panel respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card).

The online questionnaire included two questions designed to establish that respondents were paying attention. Cases that failed both attention check questions, those with over 30% item non-response, and cases with a length less than one quarter of the mean length by mode were flagged and reviewed. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, 0 cases were removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). Weighting parameters included sex, age, education, race/ethnicity, region, and education. The sample was weighted to match patterns of civic engagement from the September 2017 Volunteering and Civic Life Supplement data from the CPS and to match frequency of internet use from the National Public Opinion Reference Survey (NPORS) for Pew Research Center.  Finally, the sample was weighted to match patterns of political party identification based on a parameter derived from recent ABS polls conducted by SSRS polls. The weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 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.

Support for this work was provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Key Takeaways for the Field

• When it comes to health misinformation, few Black adults are convinced that widely circulated falsehoods are true, while much larger shares are doubtful or uncertain, providing an opportunity for intervention. When presented with specific items of health misinformation, few Black adults (between 4% and 15%) say they believe them to be “definitely true.” Modest shares (between 14% and 36%) recognize each of these claims to be “definitely false.” Similar to adults overall, when it comes to their tendency to believe false health-related statements, most Black adults fall somewhere in the middle of the spectrum, with large shares saying each claim is “probably true” or “probably false.” While most Black adults do not ardently believe the health misinformation examined in the survey, the exposure to these false and inaccurate claims may contribute to uncertainty and doubt when it comes to individual health care behaviors and choices. This more uncertain middle group may offer an opportunity for focused outreach and interventions.
• Among Black adults, some groups – including younger adults and those without a college degree – are more inclined to believe certain types of health misinformation than others, suggesting it may be helpful to target interventions to these groups. Black adults under age 50 are much more likely to say items of misinformation related to COVID-19 and vaccines are definitely or probably true compared to their older counterparts. As with adults overall, there are also large differences among Black adults in their propensity to believe health misinformation claims across educational attainment, with those without a college degree generally being more likely to say that the health misinformation items examined in the survey are definitely or probably true. This suggests that interventions aimed at preventing misinformation from taking hold may need to take a person’s broader experiences, education, and knowledge base into account.
• Personal connections maintain an outsized importance when it comes to trusted information. Black adults say that their doctors are their most trusted sources of health information. Notably, a majority of Black adults also trust the CDC, FDA, their state and local public health officials, and the Biden administration to make the right recommendations when it comes to health issues, showing potential for these official government agencies to be effective messengers to Black individuals and communities.
• Local TV news and national network news are promising ways to reach Black audiences with accurate information. Large shares of Black adults across age groups say they watch these sources regularly and would trust health information they report, ranking relatively high compared to other news sources. Online digital news aggregators, CNN, and MSNBC are also regular news sources for at least half of Black adults, though fewer say they have a lot of trust in health information reported by these sources.
• Many Black adults report regularly using social media platforms for news and current events, though fewer say they actively seek out health information on social media and few express a lot of trust in health information seen on social media. Among these platforms, Facebook and YouTube are the most widely used and have the reported highest relative levels of trust.
• Social media may be the best way to reach younger Black adults, but don’t count traditional media out. Black adults under age 35 are more likely to use social media, with majorities saying they use YouTube, Instagram, Facebook, and TikTok at least once a week, and four in ten saying they use social media at least weekly to find health information and advice, higher than for other age groups. However, majorities in this age range also say they regularly rely on local TV news and network news for information. Legacy in traditional news media remains, as younger adults report being more trusting of the information they see about health issues reported by some sources of news media rather than social media platforms.

Exposure to and Belief in Health Misinformation

While notable shares of Black adults are coming across health-related misinformation, relatively few are buying into specific false claims about COVID-19, reproductive health, and firearm violence and safety examined in the KFF Misinformation Tracking Poll Pilot. Similar to adults overall, only small shares of Black adults (15% or less) are convinced that specific items of misinformation asked about in the poll are “definitely true.” Somewhat larger shares (between 14% and 36%) reject these misinformation items as “definitely false,” yet most Black adults are in a middle group that express some uncertainty saying these false claims or “probably true” or “probably false.”

Between one in five and three in five Black adults have heard each of the pieces of health misinformation included in the survey. The most commonly heard items are that “COVID-19 vaccines have caused thousands of sudden deaths in otherwise healthy people,” “Sex education that includes information about contraception and birth control increases the likelihood that teens will be sexually active,” and “Most gun homicides in the U.S. are gang related.” Exposure to specific claims of health misinformation varies by age, gender, and education, with young Black adults and college educated Black adults being more likely to have heard pieces of COVID-19 misinformation.

Regardless of whether they have heard or read specific items of misinformation, the survey also asked people whether they think each claim is definitely true, probably true, probably false, or definitely false. For most of the misinformation items included in the survey, between three in ten and half of Black adults say they are “definitely” or “probably true.” Combining these measures, smaller shares of Black adults (between one in ten and one-third) both have heard each claim and believe it is probably or definitely true.

Measures of Health Misinformation

This report examines three measures of health misinformation among the public. Adults were asked whether they had heard or read specific, false health-related statements. Regardless of whether they have heard or read specific items of misinformation, all were asked whether they thought each claim was definitely true, probably true, probably false, or definitely false. We then combined these two measures to examine the share who have heard the false claims and believe it is definitely or probably true.

Large shares of Black adults express uncertainty about the truthfulness of the false claims tested in the survey, with majorities saying each is either “probably true” or “probably false.” Small shares – about one-third or fewer – recognize any of the claims as “definitely false,” and fewer than one in five say that any of these claims are “definitely true.”  Black adults without a college degree are particularly likely to express uncertainty about many of these claims.

The figures below show the shares of Black adults by age group and education level who believe each of the false claims is definitely or probably true. Generally, younger Black adults and those without a college degree are more likely than their older and college educated counterparts to say each of the items of misinformation examined in the survey are definitely or probably true.

Notably, about half of Black women of reproductive age (ages 18-49) say it is probably or definitely true that using hormonal birth control makes it harder for most women to get pregnant after ceasing birth control use. Older Black women lean more towards saying the statement is false, though just 15% of Black women ages 50 and older say the statement is “definitely false,” and nearly half (46%) say it is “probably false.”

Most Black parents are unsure about some of the misinformation items examined in the survey related to children, teens, and schools, with majorities saying it is “probably true” or “probably false” that armed school guards have been proven to prevent school shootings, that the MMR vaccines cause autism in children, and that sex education that includes information about contraception increases the likelihood that teens will be sexually active. One in four Black parents say the final claim is “definitely false.”

Media Consumption and Trust

Consumption of News, Social Media, and Health Information

Television is the most commonly reported medium for news consumption among Black adults ages 35 and over, with large majorities saying they regularly watch local news and national network news, and more than half saying they are regular viewers of CNN and MSNBC. Among younger Black adults, seven in ten say they regularly use digital news aggregators that draw on multiple news sources, and more than half report regularly watching various TV news sources.

Social media use, not surprisingly, varies by age among Black adults as well. A majority of Black adults across age groups report using Facebook and YouTube at least once per week, but larger shares of Black adults under age 35 say they regularly use Instagram (79%), TikTok (62%), Snapchat (49%) and Twitter (41%) compared to their older counterparts.

Regardless of preferred social media platform, many (62%) Black adults say they use social media at least once a week to keep up-to-date on news and current events. This rises to seven in ten Black adults under age 35. One-third of Black adults also say they use social media at least weekly to find health information and advice. Younger Black adults and those without a college degree are more likely than their counterparts to use social media for health advice and information.

Trust in Sources of Information

Doctors with personal relationships are the most trusted sources of health information for Black adults, with the vast majority saying they trust their doctor a great deal or a fair amount to make the right recommendations when it comes to health issues. Notably, a majority of Black adults have at least “a fair amount” of trust in the CDC, FDA, Biden administration, and state and local public health officials to make the right health recommendations. Fewer Black adults (22%) have at least a fair amount of trust in former President Donald Trump to make the right recommendations on health issues.

There are a range of sources that Black adults find at least somewhat trustworthy when it comes to health information. Majorities say they would trust health information at least a little if it was reported by most TV news sources asked about in the survey, including local and network news, CNN, MSNBC, and Fox News. At least half also say they would trust health information reported in their local newspaper, the New York Times, Wall Street Journal, or NPR. While no source garners “a lot” of trust from a majority of Black adults, at least one-third say they would trust health information “a lot” if it were reported by their local TV news station, national network news, or CNN.

Despite high use of social media platforms, fewer than one in five say that they would have “a lot of trust” in information related to health if they saw it on these platforms. Notably, however, majorities say they would trust health information at least a little if they saw it on Facebook or YouTube, and about four in ten or more say the same about Instagram, Twitter, and TikTok.

Looking at trust in news and social media sources among Black adults across age groups, local TV news stations and network news rank among the highest for trust in health information. However, across the board, few young Black adults say they would have “a lot” of trust in the health information from any source. Despite high use of social media among younger adults, Black adults under age 35 are more likely to say they would have “a lot” of trust in the health information they may come across on various traditional news sources than social media platforms such as YouTube (21%), TikTok (16%), Instagram (13%), and Twitter (13%).

This KFF Health Misinformation Tracking Poll Pilot was designed and analyzed by public opinion researchers at KFF. The survey was conducted May 23 – June 12, 2023, online and by telephone among a nationally representative sample of N=2,007 U.S. adults in English (1,881) and in Spanish (126). The sample includes 1,532 adults reached through the SSRS Opinion Panel either online or over the phone (n=78 in Spanish). The SSRS Opinion Panel is a nationally representative probability-based panel for which panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails. 1,445 panel members completed the survey online and panel members who do not use the internet were reached by phone (87).

Another 475 (n=48 in Spanish) interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Respondents in the prepaid phone samples received a $15 incentive by check received by mail, and panel respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card).

The online questionnaire included two questions designed to establish that respondents were paying attention. Cases that failed both attention check questions, those with over 30% item non-response, and cases with a length less than one quarter of the mean length by mode were flagged and reviewed. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, 0 cases were removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). Weighting parameters included sex, age, education, race/ethnicity, region, and education. The sample was weighted to match patterns of civic engagement from the September 2017 Volunteering and Civic Life Supplement data from the CPS and to match frequency of internet use from the National Public Opinion Reference Survey (NPORS) for Pew Research Center.  Finally, the sample was weighted to match patterns of political party identification based on a parameter derived from recent ABS polls conducted by SSRS polls. The weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 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.

Support for this work was provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

1. In race/ethnicity analysis throughout this report Black adults are non-Hispanic. Persons of Hispanic origin may be of any race but are categorized as Hispanic; White adults are non-Hispanic. Sample sizes for other race and ethnic groups were too small for analysis but are included in the total sample.nu00a0 ↩︎

Key Takeaways for the Field

• While large shares of Hispanic adults have heard many widely circulated falsehoods related to COVID-19, reproductive health, and guns, few are convinced that these falsehoods are true, providing an opportunity for intervention. When presented with specific items of health misinformation, few Hispanic adults (one in ten or fewer for all items except for one) say they believe them to be “definitely true,” while modest shares (between 13% and 37%) recognize each to be “definitely false.” Similar to adults overall, most Hispanic adults fall somewhere in the uncertain middle, saying each claim is “probably true” or “probably false.” While few Hispanic adults are convinced of these false and inaccurate claims, exposure to multiple pieces of health misinformation may contribute to uncertainty and doubt which could impact their health care decisions.
• Hispanic adults with lower levels of educational attainment are more inclined to believe certain false claims related to health, suggesting that efforts to address health misinformation need to be accessible to Hispanic adults with differing levels of education. This finding is consistent with the public overall, as those without a college degree are more susceptible to believing certain types of health misinformation. In addition to differences by educational attainment, partisanship plays a big role, as Republican-leaning and independent Hispanic adults are more likely to believe many health-related falsehoods than those who lean toward the Democratic party.
• Social media is an especially prominent source of health information for Hispanic adults, particularly those without a college degree and those who primarily speak Spanish. About half of Hispanic adults say they use social media at least once a week to find health information and advice, more than three times the share of White adults who say they do this. The share of Hispanic adults who use social media at least weekly for health information rises to 53% among Hispanic adults without a college degree and nearly seven in ten (69%) among Spanish speakers² . Given the large shares that seek health information and advice via social media, it may present a particularly important avenue for organizations addressing misinformation among Hispanic adults.
• Although few Hispanic adults say they would have a lot of trust in health information posted on social media, those who use social media for health advice are more open to believing health misinformation than those who don’t. While it is frequently cited as a source, few — less than one in six — Hispanic adults say they would have a lot of trust in information about health issues if they saw it on any social media platform included on the survey. However, those who rely on social media at least occasionally for health advice are more likely than those who do not seek health information on social media to have heard and believe at least one item of COVID-19 and vaccine misinformation and at least one reproductive health misinformation item. Health information and advice from social media – though it may not be entirely trusted – may nonetheless plant seeds of doubt and confusion over what information is accurate and what is false.
• Though social media use is popular among large shares of Hispanic adults, traditional media viewership and readership are also high, and some sources such as local TV news and network news are far more likely to be trusted. Television is among the most commonly reported medium for news consumption among Hispanic adults across age groups with majorities reporting regularly watching local news and national network news. These traditional news sources are also more likely to be trusted with about one in four Hispanic adults saying they would have “a lot” of trust in health information they report, suggesting that they may offer an opportunity for efforts to address misinformation.
• Spanish-speaking adults are most trusting of Spanish-language news sources and are much more likely to use WhatsApp than Hispanic adults who primarily speak English. When asked to say in their own words, what is the one news source they trust the most to provide them with reliable information, more than one in four (28%) Spanish-speaking Hispanic adults name Telemundo or Univision, while fewer name various specific English-language sources. Spanish-language sources, both news and commonly used platforms such as WhatsApp, can be useful tools for addressing misinformation among Spanish-speakers, especially in light of this population’s reliance on social media for health information and advice.
• Hispanic adults are generally trusting of the CDC, FDA, and local public health officials when it comes to health recommendations, though personal doctors are by far the most trusted messengers, highlighting the importance of personal connections. More than two-thirds of Hispanic adults have at least a fair amount of trust in the CDC, the FDA, and in their state and local public health officials to make the right recommendation on health issues and a slight majority express trust in the health recommendations from the Biden Administration. However, mirroring adults overall, personal doctors are by far the most trusted among Hispanic adults, highlighting the opportunity medical professionals have in utilizing the personal connections they have with patients to reinforce accurate health information and dispel false and inaccurate claims.

Exposure to and Belief in Health Misinformation

The KFF Health Misinformation Tracking Poll Pilot finds that, similar to adults overall, notable shares of Hispanic adults have been exposed to health-related misinformation. However, relatively few (10% or fewer on all items except for one at 17%) are convinced that the health misinformation claims included in the survey are “definitely true.” Modest shares (between 13% and 37%) fully reject these misinformation items as “definitely false.” Similar to the public overall, large shares of Hispanic adults are in a larger “muddled middle” group saying that false claims are “probably true” or “probably false.”

Between about one-third and two-thirds of Hispanic adults have heard each of the items of health misinformation included in the survey. Notably, two-thirds of Hispanic adults (67%) say they have heard the false claim that COVID-19 vaccines have caused thousands of sudden deaths in otherwise healthy people. Majorities say they have heard that sex education that includes information about contraception and birth control increases the likelihood that teens will be sexually active (56%), and that the COVID-19 vaccines have been proven to cause infertility (54%). Among Hispanic adults, certain groups are more likely to say they have encountered certain topics of health misinformation. For example, young Hispanic women are more likely than their older counterparts to say they have heard the false claim that using birth control like the pill or IUDs makes it harder for most women to get pregnant once they stop using them.

Regardless of whether they have heard or read specific items of misinformation, the survey also asked people whether they think each claim is definitely true, probably true, probably false, or definitely false. For most of the misinformation items included in the survey, between about one-quarter and six in ten Hispanic adults say they are “definitely” or “probably true.” Combining these measures, smaller shares of Hispanic adults (between one in ten and three in ten) both have heard each claim and believe it is probably or definitely true.

Measures of Health Misinformation

This report examines three measures of health misinformation among the public. Adults were asked whether they had heard or read specific false health-related statements. Regardless of whether they have heard or read specific items of misinformation, all were asked whether they thought each claim was definitely true, probably true, probably false, or definitely false. We then combined these two measures to examine the share who have heard the false claims and believe it is definitely or probably true.

Most Hispanic adults have some doubt or uncertainty about the whether the misinformation claims tested in the survey are true or not, with majorities saying each is either “probably true” or “probably false.” On all items except one at 17%, one in ten Hispanic adults or fewer say that the false claims are “definitely true.”

The largest shares of Hispanic adults express belief in two falsities related to firearms: about six in ten (57%) Hispanic adults say that the false claim that “armed school police guards have been proved to prevent school shootings” is “definitely” or “probably true,” and half (49%) say that the false claim that “most gun homicides in the U.S. are gang-related” is “definitely” or “probably true.” Hispanic adults who say they or someone in their household is a gun owner are just as likely as those who do not live with a gun owner to say each of these gun-related falsities is “probably” or “definitely true.”

The figures below show the assessments of the verity of each of the claims by Hispanic adults by educational attainment and partisanship. Generally, Hispanic adults without a college degree are more likely than their college educated counterparts to say most of the items of misinformation examined in the survey are definitely or probably true. Consistent with patterns among the public overall, Hispanic adults who identify as Republicans or lean towards the Republican Partytand out as being more likely than Democratic-leaning Hispanic adults to say most of the misinformation items are probably or definitely true. For most of the health falsities explored in this survey, there were no significant differences among Hispanic adults by primary language or nativity (U.S.-born vs. foreign-born) in their assessments.

There are fewer notable differences across age groups when it comes to Hispanic adults’ assessments of the verity of misinformation statements related to COVID-19, though those under the age of 50 are more likely to believe some falsities related to guns. A majority of Hispanic adults under age 50 say that it is “definitely” or “probably true” that armed school police guards have been proven to prevent school shootings, compared to about half of Hispanic adults ages 50 and older. Similarly, Hispanic adults under age 50 are more likely than older Hispanic adults to say it is true that people with firearms at home are less likely to be killed by a gun than people who do not have a firearm. For both of these false statements, this difference is mostly driven by the larger share of younger adults who say the statements are “probably true.”

A majority of Hispanic women of reproductive age (ages 18 to 49) say it is probably or definitely true that using hormonal birth control makes it harder for most women to get pregnant after ceasing birth control use, while most Hispanic women ages 50 or older say it is probably or definitely false.

Most Hispanic parents are unsure about some of the misinformation items examined in the survey related to children, teens, and schools, with a majority saying it is “probably true” or “probably false” that armed school guards have been proven to prevent school shootings, that the MMR vaccines cause autism in children, and that sex education with information regarding contraception increases the likelihood that teens will be sexually active. About one in four Hispanic parents (26%) say it is “definitely false” that MMR vaccines cause autism or that comprehensive sex education increases the likelihood that teens would be sexually active (25%).

When it comes to COVID-19 and vaccines, belief in misinformation is correlated with Hispanic adults’ individual vaccination status: while nearly nine in ten Hispanic adults who indicate that none of the items of vaccine or COVID misinformation presented are true are vaccinated against COVID-19, fewer (63%) Hispanic adults who believe between 3 and 5 items of COVID misinformation say they are vaccinated against the virus.

Media Consumption and Trust

Consumption of News, Social Media, and Health Information

Television is the most commonly reported medium for news consumption among Hispanic adults across age groups with large majorities saying they regularly watch local news and national network news. For Hispanic adults under age 55, digital news aggregators that draw on multiple news sources are consumed on par with television news. Few Hispanic adults across age groups report regular consumption of conservative national news networks such as OANN or Newsmax, though about four in ten Hispanic adults under age 55 and about a third of those age 55 or older say they regularly watch Fox News.

Social media use, not surprisingly, varies by age among Hispanic adults as well. At least seven in ten  Hispanic adults across age groups say they use Facebook at least once per week. A majority of Hispanic adults under age 55 also regularly use YouTube and Instagram. At least one-third of Hispanic adults across age groups use WhatsApp at least weekly, rising to 87% of Spanish-speaking Hispanic adults, likely reflecting high international use of this app. Hispanic adults under age 35 are much more likely than those 35 and older to regularly use Instagram TikTok (61%), Snapchat (52%), and Reddit (26%).

When asked to say in their own words, what is the one news source they trust the most to provide them with reliable information, regardless of the sources asked about explicitly in the survey, more than one-third (28%) of Spanish-speaking Hispanic adults say Telemundo or Univision, while fewer name various specific English-language sources. In-language sources, both news and commonly used platforms such as WhatsApp, can be useful tools for addressing misinformation among Spanish-speakers and the Hispanic community generally.

Regardless of preferred social media platform, seven in ten Hispanic adults use social media at least once a week to stay up to date on news and current events. This rises to three-fourths of Hispanic adults under age 35 and eight in ten Hispanic adults who primarily speak Spanish. Half of Hispanic adults (49%) – compared to just 15% of White adults and about a third of Black adults – use social media regularly to find health information and advice. Similar shares across age report this, but this rises to half (52%) of Hispanic adults without college degrees and seven in ten (69%) Hispanic adults who primarily speak Spanish.

Among Hispanic adults, the use of social media, even occasionally, for health information and advice is correlated with hearing and believing items of health misinformation. For example, at least half of Hispanic adults who use social media for health information and advice say that they have heard at least one of the false COVID-19 or vaccine claims tested in the survey and think it is definitely or probably true, compared to about one-third of those who don’t use social media for health advice.

Trust in Sources of Information

Doctors with personal relationships are the most trusted sources of health information for Hispanic adults, with the vast majority saying they trust their doctor “a great deal” or a “fair amount” to make the right recommendations when it comes to health issues. Notably, a large majority of Hispanic adults have at least “a fair amount” of trust in the CDC, FDA, and their local public health officials. Hispanic adults are more divided when it comes to trust in health recommendations from the Biden administration and former President Trump, with a slight majority saying they would have at least a fair amount of trust in the Biden administration to make the right health recommendations, while four in ten would have at least a fair amount of trust in former President Trump. Democratic-leaning Hispanic adults are more trusting of the current administration, while Republican-leaning Hispanic adults are more trusting of the former president’s recommendations. Overall, recommendations from government agencies are deemed trustworthy but even more likely to be trusted when presented by their personal doctors. Health recommendations from political actors are unlikely to be trusted by those of the opposing partisan persuasion.

There are a range of news sources and platforms that Hispanic adults find at least somewhat trustworthy when it comes to health information. At least half say they would trust health information at least a little if it was reported by most TV news sources including local and network news, CNN, MSNBC, and Fox News. Nearly three in four also say they would have at least a little trust in health information reported in their local newspaper and six in ten say they would trust it if they saw it reported by the New York Times. While no source garners “a lot” of trust from a majority of Hispanic adults, at least one-quarter say they would trust health information “a lot” if it were reported by their local TV news station, national network news, or CNN.

Despite high use of social media platforms, fewer than one in six Hispanic adults say that they would have “a lot of trust” in health information if they saw it on these platforms. Two-thirds say they would trust health information at least a little if they saw it on YouTube, and about half say the same about Facebook and Instagram. Notably, WhatsApp – despite being used at least once per week by half of Hispanic adults – ranks low in terms of how much health information would be trusted on the platform, with just 8% of total Hispanic adults saying they would trust information on the platform “a lot,” rising to 12% among users of the app.

This KFF Health Misinformation Tracking Poll Pilot was designed and analyzed by public opinion researchers at KFF. The survey was conducted May 23 – June 12, 2023, online and by telephone among a nationally representative sample of N=2,007 U.S. adults in English (1,881) and in Spanish (126). The sample includes 1,532 adults reached through the SSRS Opinion Panel either online or over the phone (n=78 in Spanish). The SSRS Opinion Panel is a nationally representative probability-based panel for which panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails. 1,445 panel members completed the survey online and panel members who do not use the internet were reached by phone (87).

Another 475 (n=48 in Spanish) interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Respondents in the prepaid phone samples received a $15 incentive by check received by mail, and panel respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card).

The online questionnaire included two questions designed to establish that respondents were paying attention. Cases that failed both attention check questions, those with over 30% item non-response, and cases with a length less than one quarter of the mean length by mode were flagged and reviewed. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, 0 cases were removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). Weighting parameters included sex, age, education, race/ethnicity, region, and education. The sample was weighted to match patterns of civic engagement from the September 2017 Volunteering and Civic Life Supplement data from the CPS and to match frequency of internet use from the National Public Opinion Reference Survey (NPORS) for Pew Research Center.  Finally, the sample was weighted to match patterns of political party identification based on a parameter derived from recent ABS polls conducted by SSRS polls. The weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 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.

Support for this work was provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

1. In race/ethnicity analysis throughout this report, persons of Hispanic origin may be of any race but are categorized as Hispanic; Black adults are non-Hispanic; White adults are non-Hispanic. Sample sizes for other race and ethnic groups were too small for analysis but are included in the total sample.nu00a0 ↩︎
2. Spanish-speaking Hispanic adults are those who identified as Hispanic and opted to complete the survey in Spanish. ↩︎

In July 2023, the U.S. Food and Drug Administration (FDA) approved the first over-the-counter (OTC) daily oral contraceptive pill, Opill. Despite years of OTC access to contraception such as Plan B and condoms, there has been little research on how private insurance plans or Medicaid programs cover non-prescribed OTC contraception and whether they do so without cost-sharing. Currently, federal law requires most private health insurance plans and Medicaid expansion programs to cover, without cost-sharing, the full range of FDA-approved contraceptive methods. Health plans usually require a prescription to indicate medical necessity and trigger coverage, including for methods that do not require a prescription to purchase. Traditional Medicaid programs are required to cover family planning services without cost-sharing, though states have flexibility in which contraceptive methods they cover.

Earlier this year, the Biden administration issued an executive order directing the U.S. Departments of Labor, Health and Human Services, and Treasury to consider new actions to improve access to affordable contraception, which includes promoting increased access to and coverage of OTC contraception at no costs to consumers. Currently, the guidance from these three agencies “encourages” private plans to cover OTC contraceptives without cost-sharing but does not require it.

Six states, however, have passed laws requiring state-regulated health plans to cover, without cost-sharing, certain OTC contraception without a prescription and seven states use state-only funds to provide this coverage for Medicaid enrollees. Twenty-seven states and D.C. have expanded pharmacist prescribing of at least some contraceptive methods, which could facilitate coverage of OTC methods but few pharmacists have training or time, and those that do, are not compensated for counseling patients.

This report is based on 35 structured interviews conducted from January to August 2023, with nearly 80 experts and key players such as pharmacists, health plans, and state Medicaid officials involved in the coverage and provision of OTC contraception in seven states with one or more of these coverage approaches (IL, NJ, NM, NY, OR, UT, and WA). It discusses the challenges and opportunities identified by the interviewees that they have experienced regarding coverage under private health insurance and Medicaid and reviews potential options for operationalizing insurance coverage of non-prescribed OTC contraception such as Opill. These experiences are also informed by recent policies that required plans to pay for OTC COVID tests and more recently by interest in expanding access to Narcan, now available without a prescription.

With the imminent availability of Opill and the possibility of a new OTC oral contraceptive pill in the near future, the issue of coverage has been raised by many stakeholders. While some states have moved forward with coverage requirements for OTC contraceptives, operational issues and concerns such as pharmacy and pharmacists’ capacity to submit claims for OTC products, a lack of uniformity and oversight of health plans’ billing protocols, and low awareness of these policies remain as implementation challenges. While required coverage of OTC contraception without a prescription and without patient cost-sharing would increase access, it could also create a precedent for coverage of other OTC treatments, raising issues of cost for insurers and state Medicaid programs.

Key Takeaways

• Across the spectrum of stakeholders interviewed, there is interest and engagement about the potential of an over-the-counter (OTC) contraceptive pill to broaden access to contraceptive options, but many raised concerns about challenges related to affordability, implementation, and coverage options based on experiences in several states.
• In states where OTC methods are currently covered without a prescription by Medicaid or private plans, consumers generally need to obtain OTC contraception at the pharmacy counter, where they can show evidence of coverage and get their pharmacy claim processed. In some private health plans, consumers can pay for OTC contraception up front and then seek reimbursement from the plan, but that could be financially and administratively burdensome for consumers and is rarely used.
• Interviewees indicated that there has been little specific outreach about this covered benefit to pharmacies in states where OTC contraception, such as emergency contraception and condoms, is covered without a prescription in private insurance or for Medicaid enrollees. Health plan interviewees reported that they receive few claims for non-prescribed OTC contraception, which could be due to low awareness of the benefit and how to bill for it. Few plans provide information about the benefit in their enrollee-facing information.
• State Medicaid programs need to submit a State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) to cover OTC drugs and products. After obtaining this authorization, states can determine which OTC drugs and products their Medicaid programs will cover. However, federal Medicaid law requires a prescription to cover all drugs, even those that are available without a prescription. A few states have chosen to use their own funds, without federal matching dollars, to pay for OTC contraceptives for Medicaid enrollees without a prescription. Federal funds will remain unavailable to cover OTC drugs without a prescription unless Congress amends the federal Medicaid law.
• In states where coverage for OTC contraception is provided without a prescription, interviewees noted that billing protocols for OTC contraception vary widely by health insurance plan and even within state Medicaid programs, leading to confusion for some pharmacists. States/state agencies do not usually determine the billing mechanism to be used.
• Some interviewees raised the importance of addressing quantity limits for OTC contraception. Interviewed health plans and a national PBM suggested that quantity limits have the potential to control fraud, waste, and abuse, which they cited as leading to higher costs for insurers.
• There has been limited communication about billing for non-prescribed OTC contraception between pharmacies, PBMs, health plans, and state insurance departments. Many interviewees from these sectors expressed that the mechanics of these state laws and how to operationalize them are unclear.
• While several interviewees expressed confidence that their current billing process for other non-prescribed OTC contraception can easily accommodate, most state-level discussions on insurance coverage of this product are in the preliminary stages.
• In some states, pharmacist prescribing plays an integral intermediary role in access to contraception where a prescription is required for coverage by removing the need to obtain a prescription from a physician or other prescriber. However, challenges and shortcomings with this approach persist, such as pharmacist time constraints, training requirements, and low or no payment from health plans for pharmacists’ services.
• When interviewees were asked what general suggestions they had for how to best implement coverage for Opill without a prescription, many stressed the importance of having a standardized billing process to help facilitate the transition to covering OTC contraception such as without a prescription as well as the role of clearer federal guidance regarding what plans are required to cover.
• While state actions to increase access to non-prescribed OTC contraception without cost-sharing can be meaningful for people with private insurance, the reach of these actions is limited, in large part because the majority of those with private health insurance are enrolled in self-funded employer plans, which are not subject to state insurance requirements.
• The extent to which OTC contraceptive pills can broaden the availability of effective contraceptives to those who seek them will depend on many factors including state and federal policies, pharmacy engagement, pharmacy stocking and signage, religious refusals, affordability, and insurance coverage, as well as public awareness and education.

This report is based on 35 structured interviews conducted from January to August 2023, with nearly 80 experts and key players such as pharmacists, health plans, and state Medicaid officials involved in the coverage and provision of OTC contraception in seven states with one or more of these coverage approaches (IL, NJ, NM, NY, OR, UT, and WA). It discusses the challenges and opportunities identified by the interviewees that they have experienced regarding coverage under private health insurance and Medicaid and reviews potential options for operationalizing insurance coverage of non-prescribed OTC contraception such as Opill. These experiences are also informed by recent policies that required plans to pay for OTC COVID tests and more recently by interest in expanding access to Narcan, now available without a prescription:

• Background
• Lessons Learned from Key Informant Interviews
• Discussion

Background

Oral contraceptives are the most commonly used method of reversible contraception in the U.S. Oral contraceptive pills were first approved for prescription use by the U.S. Food and Drug Administration (FDA) in 1960. In July 2023, the FDA approved Opill, the first daily oral contraceptive pill available over-the-counter (OTC) without a clinician or provider’s prescription. It is expected to be available in early 2024.

OTC status is an FDA designation meaning that a drug or product is available without needing a prescription from a health care provider. The ability to access oral contraceptives without a prescription from a clinician can save time spent on travel, at a clinician’s office, and off work or school. Studies suggest that OTC access to oral contraceptives would increase the use of contraception, facilitate continuity of use, and reduce the risk of unintended pregnancy.

Most drugs available OTC today were initially labeled and approved as prescription-only medications. Other commonly known OTC drugs that were previously only available with a prescription include levonorgestrel emergency contraceptive pills; smoking cessation aids such as Nicorette; several brands of allergy medications such as Claritin D, Allegra, and Zyrtec; heartburn medication such as Prilosec; and Narcan nasal spray, the most recent product to switch from prescription to OTC status before Opill, which is used to treat opioid overdoses.

Levonorgestrel emergency contraceptive (EC) pills, marketed as Plan B One-Step and other brands, are a form of backup birth control intended to be taken within three days after unprotected sex or contraceptive failure to prevent pregnancy. They were the first contraceptive pills to have switched from prescription to OTC status, in 2006. While EC pills were originally FDA-approved for OTC use by people ages 17 and older, the FDA removed the point-of-sale age requirement in 2014. Unlike daily oral contraceptives, EC pills are not intended for daily use.

Other contraceptive products that are available over the counter without a prescription include external condoms, spermicides, and contraceptive sponges. These non-hormonal contraceptive methods are less effective than oral contraception at preventing pregnancy. The FDA’s approval of Opill will make it the most effective method of contraception available over the counter intended for regular use.

FDA Prescription-to-OTC Switch Process

The FDA requires applicants to conduct extensive testing, often over several years, of products and labeling before they can be approved for OTC use. Opill’s application was approved through the “RX-to-OTC switch” pathway, which is available for drugs that have already been approved by the FDA, like Opill, by submitting a New Drug Application (NDA). Medications may be eligible for OTC status if the FDA determines that they can be used appropriately by consumers for self-diagnosed conditions; they do not require a clinician for safe and effective use; and they have a low potential for misuse and abuse. Applicants typically must conduct studies to assess whether consumers are able to comprehend the product’s labeling and use the product safely and appropriately without the supervision of a clinician.

Opill, a daily progestin-only oral contraceptive, was initially approved for prescription use by the FDA in 1973 (manufactured by Pfizer under the brand name Ovrette). HRA Pharma acquired the rights to Opill in 2015 and began the research process required to apply to the FDA for an Rx-to-OTC switch, including label comprehension studies and self-selection actual use trials. HRA Pharma, subsequently acquired by Perrigo in April 2022, submitted its application to move Opill over the counter in July 2022.

In addition to review by the FDA itself, the process often also entails review by independent advisory committees comprised of scientific experts and consumer representatives. In May 2023, after reviewing evidence and hearing public testimony, FDA advisory committees unanimously voted in favor of the FDA moving Opill over the counter. Although the FDA is not required to follow advisory committees’ recommendations, they typically do. The FDA approved Opill for OTC use on July 13, 2023, without age restrictions, and the manufacturer reports that it will be available in stores and online in early 2024. Consumers will be able to purchase a pack of one, two, three, or six months’ worth of pills, depending on availability.  

Although it is farther behind in the process, another pharmaceutical company, Cadence, is working toward FDA approval of an OTC version of its combined (progestin and estrogen) oral contraceptive pill, Zena. Cadence is reported to be considering a different FDA pathway to OTC status that has been proposed by the Biden administration.

Federal and State Laws on Coverage of OTC Contraception

MEDICAID

Medicaid is the joint federal/state health insurance program for people with low incomes. Federal law requires state Medicaid programs to cover family planning services and supplies without cost-sharing, but they are not required to cover OTC products (with a few exceptions) or to cover OTC contraception without a prescription. States cannot obtain federal matching dollars for covering a medication without a prescription, but they may opt to use state-only funds to cover OTC drug benefits without a prescription.

Seven states (CA (effective in 2024), IL, MD, MI, NJ, NY, and WA) cover, with state funds, at least some OTC contraceptive methods without a prescription for Medicaid enrollees. Note that New Jersey Medicaid’s coverage of non-prescribed OTC contraception applies to fee-for-service (FFS) enrollees only, which represent 2% of enrollees in the state. With the exception of California, coverage is specific to emergency contraception or condoms in these states, so these programs may not include Opill without a change in policy. (See Over-the-Counter Oral Contraceptive Pills for the coverage details of these and other state Medicaid programs.)

PRIVATE INSURANCE

The Affordable Care Act (ACA) requires most private health plans (individual, small group, and large group) to cover recommended preventive services without cost-sharing. The ACA tasks the Health Resources and Services Administration (HRSA) with recommending coverage requirements for a range of preventive services for women, which initially consisted of eight recommendations that included contraceptive services and supplies, identified by a committee of the Institute of Medicine in 2011. The initial HRSA 2011 recommendation included the language “as prescribed” in reference to the coverage requirement for contraception. Today, the Women’s Preventive Services Initiative (WPSI) is the expert body currently commissioned by HRSA to issue and update preventive clinical recommendations for women. WPSI updated its contraceptive coverage recommendation in 2021 and it does not include a prescription requirement for coverage of contraception. HRSA dropped the prescription requirement in its language when the preventive services guidelines were updated and posted. Currently, “as prescribed” is only referenced in the U.S. Departments of Labor, HHS, and Treasury (“tri-agency”) federal FAQs.

In addition to the federal ACA requirements, six states (CA (effective in 2024), MD, NJ, NM, NY, and WA) have laws or regulations requiring state-regulated private health insurance plans (individual and fully-insured employer-sponsored plans) to cover, without cost-sharing, OTC contraception without a prescription. Nationally, 65% of workers with employer-sponsored insurance are enrolled in a self-funded plan; therefore, the majority of people with employer-sponsored insurance who live in states that require coverage of OTC contraception without a prescription are not guaranteed this coverage. While the language of New York’s law is specific to emergency contraception, the other state laws apply to a broad range of contraception. The language of these laws, with the exception of New York’s, is broad enough to include a daily oral contraceptive pill such as Opill without a change in policy. (See Over-the-Counter Oral Contraceptive Pills for the details of these state laws and others that require coverage without a prescription.)

Illinois and Oregon require private health plans to cover OTC contraception; however, while these laws do not state that a prescription is required in order for it to be covered by insurance, the laws also do not explicitly stipulate that plans must cover them without a prescription. While federal law applies to all private plans, state law applies to only individual plans and fully-insured employer plans.

Pharmacist Prescribing

In states where coverage of OTC contraception without a prescription is not possible, not required, or where billing requirements are unclear, pharmacist prescribing is a relatively novel approach that can help expand access and bridge that gap. States, rather than the federal government, establish standards that determine the scope of practice and services that may be provided by different types of licensed health practitioners practicing in that state. Twenty-seven states and D.C., including all seven in this study, have passed laws permitting pharmacists to prescribe certain methods of contraception, including OTC contraception, or to dispense it pursuant to a standing order or collaborative practice agreement (discussed in more detail later in the report). In these states, consumers can obtain a prescription for contraception, including OTC methods, at a participating pharmacy without the need for a visit to a clinic or doctor’s office. Expanded scope of practice can help facilitate private insurance and Medicaid coverage of these products and research demonstrates that it can increase access to contraception and help prevent unintended pregnancies.

However, many states do not have laws that permit pharmacist prescribing, and in the states that do, there are many limitations with pharmacy prescribing, including low pharmacy and pharmacist take-up, pharmacist training requirements, and patient counseling and evaluation requirements, which are typically provided without payment from health plans. Although the FDA did not place an age restriction on access to Opill, some states place age restrictions on pharmacists prescribing contraception to people under the age of 18. Additionally, a consumer who wants pharmacist-prescribed contraception is not able to do so outside of pharmacy hours or when the pharmacist is unavailable to provide this service. Because pharmacist prescribing is still a clinical model and patients in most states must disclose personal health data during the consultation, this approach may present barriers for people who do not wish to interact with the health care system.

(Back to top)

Lessons Learned from Key Informant Interviews

To identify experiences and approaches for plans to cover OTC contraceptives, key players in states that require or allow for private insurance or Medicaid coverage of OTC contraception without a prescription, including some that allow pharmacists to prescribe contraception, were interviewed. After identifying states that implemented at least one of these insurance coverage or pharmacist prescribing policies, while also factoring in interviewing logistics, seven states were included in the project: Illinois, New Jersey, New Mexico, New York, Oregon, Utah, and Washington.

From January 2023 through August 2023, KFF staff completed 35 interviews with nearly 80 experts from state Medicaid programs, the Centers for Medicare and Medicaid Services (CMS), state insurance departments, private health insurance plans, Medicaid managed care organizations (MCOs), chain pharmacies, independent pharmacies, a pharmacy benefit manager (PBM), and trade associations, as well as pharmacists and contraceptive access advocates.

The information collected from the interviews highlights state policies and strategies that have been used to operationalize Medicaid and private insurance coverage of OTC contraception such as Opill, as well as identifies the approaches and challenges to help inform state and federal efforts to address coverage for Opill. To preserve interviewees’ confidentiality, individual names, affiliations, and states are not provided. (See the Methods section for more details.)

State-Funded Coverage of OTC Contraceptives Without a Prescription for Medicaid Enrollees

The specifics of coverage of family planning services and supplies vary across Medicaid programs. Four of the seven states that participated in the study confirmed they pay for non-prescribed OTC contraception for Medicaid enrollees (IL, NJ, NY, and WA). (As mentioned above, New Jersey’s coverage applies only to FFS enrollees.) Because federal Medicaid law requires a prescription to trigger coverage of drugs and products, these coverage policies are entirely state-funded. New Jersey and New York only cover non-prescribed OTC emergency contraceptive pills while Illinois and Washington cover non-prescribed OTC emergency contraceptive pills and other OTC contraceptives such as condoms.

In states that cover non-prescribed OTC contraception for Medicaid enrollees using state-only funds, there are generally two mechanisms pharmacists use to bill for them and get reimbursed from the state.

1. Universal National Provider Identifier (NPI) number: NPIs are unique, 10-digit numbers issued by CMS that identify individual providers or health care entities, such as pharmacies, which are used for billing purposes. Across the Medicaid programs that cover non-prescribed OTC contraception using state funds, this is the most common mechanism pharmacists use to submit a claim without enrollee cost-sharing. According to interviewees, this process involves the pharmacist entering a dummy, blank, or state-specific universal NPI in the prescriber field. It is used by three state Medicaid programs and some MCOs in the study.
2. Pharmacy NPI: In this process, the pharmacist enters the pharmacy’s NPI in the prescriber field. It is used by one state Medicaid program and several Medicaid MCOs, and it was formerly used by one state Medicaid program that used to cover non-prescribed OTC emergency contraception but no longer does.

While each of the four state Medicaid programs published billing guidance and/or resources on the coverage benefit, pharmacist and consumer awareness of the benefit is generally low. Pharmacist training and billing guidance vary across states. Some state Medicaid programs are unaware of any issues with their billing mechanism for non-prescribed OTC emergency contraception, but others have cited that some pharmacists are unaware or unsure of the billing process for contraception despite billing guidance provided through pharmacy handbooks, newsletters, and email or fax blasts. As one pharmacist pointed out, part of the confusion stems from the fact that they are dealing with many plans and there is no standardized method of communicating this information or a single source for a pharmacist to find this information.

Billing mechanisms can also differ between traditional FFS Medicaid and MCOs. For example, in one state Medicaid program, pharmacists billing for non-prescribed OTC contraception are instructed to use a dummy NPI number in the prescriber field for their FFS program, the pharmacy’s NPI for one MCO, and dummy NPIs for other MCOs. These different billing mechanisms can lead to pharmacist confusion and additional administrative burdens.

Most state Medicaid programs studied indicated they have not recently reviewed claims data for non-prescribed OTC contraception or do not know how often claims are submitted for it. State Medicaid programs do not directly advertise the benefits to beneficiaries outside of the member handbook. Several pharmacists corroborated that awareness of this benefit among pharmacists and consumers is low.

One of the three states that does not currently cover OTC contraceptives for Medicaid enrollees discontinued funding for non-prescribed contraception in 2016. The program was reportedly discontinued due to lack of utilization, and one pharmacy owner mentioned the process was tedious for both pharmacists and patients. The program was administered through the state health department and was paid for using state funds and involved pharmacists billing Medicaid using the pharmacy’s NPI. State Medicaid officials have not discussed restarting the program.

In general, Medicaid fee-for-service enrollees cannot file a claim if they did not obtain point-of-sale coverage for non-prescribed OTC emergency contraception. However, an FQHC-based Medicaid MCO in one state that covers non-prescribed OTC contraception reported that enrollees can purchase the OTC contraceptive out-of-pocket and then submit a receipt to the MCO for reimbursement.

Private Insurance Coverage of OTC Contraceptives Without a Prescription

The project included four of the states that currently require state-regulated private health insurance plans to cover at least some methods of OTC contraception without a prescription (NJ, NM, NY, and WA). Oregon and Illinois, also included in the study, have laws requiring coverage of OTC contraception, but coverage without a prescription is not explicit and interpretation of the laws varies. Nonetheless, some health plans in these states do cover OTC contraception without a prescription.

In states where private insurers are required to cover OTC contraception without a prescription, there are generally two pathways for consumers to receive coverage.

1. Obtaining the OTC contraceptive product at the pharmacy counter: The private plans interviewed said that consumers can bring their OTC products to the pharmacy counter and the pharmacist would then submit a claim to the plan using their own national provider identifier (NPI) number, pharmacy NPI number, or dummy NPI depending on the plan and state protocol. Enrollees usually must purchase it from an in-network pharmacy in order for it to be covered. This approach is similar to how pharmacists billed for at-home COVID-19 tests in many situations.
2. Purchasing the OTC contraceptive product at the cashier outside of the pharmacy and getting reimbursed: One private plan mentioned that consumers can also purchase the product outside of a pharmacy setting and then submit a claim with the receipt to their insurance company for reimbursement, similar to the reimbursement mechanism that was used for some at-home COVID-19 tests. While this option generally expands access to coverage in certain situations, such as when a pharmacy inside a store is closed, it could pose financial and logistical barriers by requiring enrollees to pay the cost upfront and navigate the plan’s reimbursement process, which may require the enrollees to include a prescription number.

Some health plans voluntarily provide coverage for OTC contraceptives without a prescription in states that do not mandate coverage. The state insurance department for one state without an OTC contraceptive coverage requirement noted there are a few private health plans that voluntarily cover non-prescribed OTC contraception. Corroborating this notion, one private health insurance carrier that operates in a state where coverage of non-prescribed OTC contraceptives is required also voluntarily extends the same coverage in the three other states where the carrier operates, which do not have this requirement, as long as the drug or product is included on the drug formulary. A formulary is the list of drugs covered by a specific health insurance plan. If a drug is not listed on a plan’s formulary, it is likely not covered by the plan and the enrollee would need to pay out-of-pocket for it.

Despite state coverage requirements, the health plans in the study indicated that claims for non-prescribed OTC contraception are rare, suggesting a lack of awareness of this covered benefit among pharmacists and health plan enrollees. Indeed, two independent pharmacy owners in a state with this coverage requirement indicated that they were unaware of or unfamiliar with this private insurance policy. Representatives from another state’s insurance department stated that it is the health plans’ responsibility to inform their members of any new benefits to which they are entitled. Some state insurance departments indicated that health plans are required to notify their enrollees that this coverage is available or include the information in their membership materials, though the details of how and where that information is communicated is largely up to the plan.

Some contraceptive access advocates cited concerns that raising consumer awareness and expectations about this covered benefit without better operational structures could generate confusion among enrollees with employer-sponsored insurance. Coverage requirements for OTC contraception only apply to state-regulated private health plans (individual and fully-insured employer-sponsored plans). However, the majority of covered workers are enrolled in self-funded plans, to which state coverage requirements do not apply. Two national advocates, who also work with state-level advocates, noted that broadly promoting coverage awareness can misguide and mislead many consumers who are in self-funded plans into thinking they are guaranteed this coverage because self-funded and fully-insured plans typically look the same to the enrollee so they may not know they are in a self-funded plan. Some states, such as Colorado, Maryland, and New Jersey, require insurance cards to indicate whether the plan is regulated by the state, but most states do not.

Even with state laws requiring coverage, insurance commissioners have not issued guidance on how private health plans should process claims for non-prescribed OTC contraception. Representatives from one state’s department of insurance confirmed that billing mechanisms for OTC contraceptives vary across health plans, with some plans having their pharmacy networks set up to detect the products as zero cost-sharing and others requiring enrollees to submit claims to the insurer for reimbursement. The various ways of billing private insurance can consequently lead to pharmacist confusion.

State compliance and enforcement efforts vary. One state department of insurance addresses compliance on a case-by-case basis, primarily relying on complaints from consumers or providers to trigger a compliance review. This state insurance department noted that while there was some confusion among insurers about the mechanics of the coverage law when it took effect, they have received very few complaints. Another state insurance department takes a different approach to ensuring compliance with state coverage laws by conducting systematic reviews periodically, in addition to addressing individual complaints they receive from consumers and providers, which they note are rare. However, a pharmacist and a representative from a pharmacy chain noted that even with state mandates, getting payers to operationalize coverage is difficult.

Billing for OTC contraceptives varies across PBMs. PBMs help establish standard formulary processes while ensuring the insurers and pharmacies they contract with abide by state and federal policies. One national PBM interviewee noted that coverage for OTC drugs typically requires a prescription in order for the claim to adjudicate through their pharmacy system. In states with laws that require private insurers to cover non-prescribed OTC contraceptives, a health plan interviewee explained that their members need to mail in receipts to be reimbursed for the out-of-pocket purchase. However, as other interviewees shared, there have been few claims for these non-prescribed OTC contraceptives.

Both payers/PBMs and pharmacies experience challenges with claims submission due to historical systems and processes that were not built for widespread coverage of non-prescription products. For example, one health plan explained that most chain pharmacy systems require an NPI to submit a claim and that most payer claim systems also require an NPI to adjudicate the claim. While the payer could in theory opt not to require an NPI, the pharmacy system would still require it. As a result of these collective limitations, workarounds at the pharmacy and health plan level may be necessary when billing for non-prescribed OTC contraception, creating additional burden on community pharmacy staff.

Some pharmacists are concerned that billing health plans for non-prescribed OTC contraceptives may trigger an audit from PBMs. Some pharmacists said they worry about being audited by PBMs, as these billing mechanisms appear to contradict the training they have received about billing thoroughly and carefully to avoid auditing. One pharmacy chain representative shared this concern as well since failed audits can result in penalties and loss of compensation for pharmacies. However, representatives from a private health insurance plan and a Medicaid managed care organization stated that their PBM excluded OTC categories from being auditable.

Some pharmacists also reported being concerned about potential legal liability for billing without a prescription. When a pharmacist uses their NPI, the pharmacy’s NPI, or a dummy NPI to bill for an OTC drug, it can give the impression that a prescription has been written for it. Some pharmacists in these states raised concerns about potential legal liability in the event that a patient claims a pharmacist made a mistake because no prescription was actually written.

Clear communication between PBMs, health plans, and pharmacies can help facilitate coverage for OTC contraceptives. The health plan above noted that their PBM notified network pharmacies that coverage for OTC contraceptives is a new capability that pharmacies in the state must comply with. The PBM also sent out billing guidance on how to bill for OTC contraceptives. Clear communication can help reduce confusion about different billing mechanisms and alleviate concerns about being audited.

The Role of Pharmacist Prescribing

Four (NM, OR, UT, and WA) of the seven states in the study currently permit pharmacists to prescribe contraception; two states (IL and NJ) recently passed pharmacist prescribing laws and are still in the process of implementing them; and one state (NY) passed a pharmacist prescribing law in May 2023 that will take effect at the end of 2024. (See Appendix Table 1 for details on each state’s law.)

Pharmacist prescribing plays a key role in coverage of contraception without cost-sharing in some states. Many interviewees stated that pharmacist prescriptive authority helps expand access to reproductive health care. Prescribing authority varies by state and is typically issued through a standing order, collaborative practice agreement, statewide protocol, or full prescriptive authority (Table 1). Where this is an option, pharmacist prescribing helps reduce barriers to accessing contraception by removing the need to visit a clinician to obtain a prescription, and for people without insurance, it can be less expensive than getting a prescription from a clinician.

Uptake of prescriptive authority has been low among pharmacists in some states, in part because of the training requirements. In many states, including one in the study, pharmacists graduating from the state university’s pharmacy school earn prescriptive authority upon graduation. However, prescriptive authority for hormonal contraception usually involves continuing education which takes time and resources outside the standard responsibilities of a pharmacist. An executive pharmacy director for a Medicaid managed care organization stated that even though their state allows pharmacists to prescribe hormonal contraceptives via a standing order, it is uncommon for pharmacists to use this option.

While pharmacist prescribing can promote access to contraception, shortcomings of this approach may persist for several reasons. The most commonly cited reasons include:

• Lack of or limited compensation for consultation is a barrier to participation in pharmacist prescribing. Most pharmacists and independent community pharmacy leadership mentioned that pharmacists in their state are not incentivized to prescribe or dispense hormonal contraception due to the lack of payment from health plans for the service. Several pharmacy interviewees cited challenges getting private insurance to compensate pharmacists for this service. This challenge is in part due to the fact that insurance companies typically do not recognize pharmacists as providers and adhere to credentialing and enrollment processes that are typically reserved for traditional health care providers vs. pharmacists. While pharmacies are reimbursed for the cost of the drug, pharmacist services for patient counseling and evaluation, prescribing, and other administrative services associated with providing this service are often not compensated by payers or are paid at a low rate. Representatives from a pharmacy chain said that when pharmacy services are paid, whether the payment goes to the pharmacy or to the pharmacist depends on the arrangement pharmacists have with their employer. One pharmacist noted that payment typically goes to the pharmacy rather than to the pharmacist. Lack of or low compensation can sometimes lead pharmacies to charge patients consultation fees in lieu of payer compensation, which is at odds with the goal of the ACA and Medicaid to eliminate financial barriers to contraceptive services for patients. One pharmacy interviewee reported that they do not prescribe many OTC products for this reason:

• Lack of prescriptive authority where it is permitted: As mentioned above, it may be difficult to locate pharmacies with at least one prescribing pharmacist, even in states with many prescribing pharmacists. One interviewee said their data showed pharmacist prescribing is more prevalent in urban areas than rural areas. Since prescriptive ability is optional to most pharmacists, consumers may encounter inconsistent availability of pharmacists willing or able to prescribe hormonal contraception. This gap is particularly prevalent in rural areas that already face declining access to pharmacies. However, other studies suggest that pharmacists in rural communities are just as likely to prescribe contraceptives as those in urban communities.
• Lack of time: The role and scope of pharmacists in health care has rapidly expanded over the years, with a growing number of pharmacists dispensing medication, administering vaccines, and counseling patients, among other services. Several interviewees expressed that prescribing contraceptives and adjudicating coverage for OTC contraceptives adds another layer of responsibility for pharmacists who are already overstretched. The process often involves a pharmacist consultation, drug utilization review, blood pressure check, and patient education, all of which take time to complete and can interrupt workflow. For these reasons, even if there are pharmacists who can prescribe at a pharmacy, patients may have to wait to obtain a prescription for contraception. Additionally, pharmacists are generally required to enroll as a Medicaid provider in order for Medicaid to compensate for their services, which can be a burdensome process depending on the state.

When asked what suggestions they would have for other states considering implementing pharmacist prescribing, some pharmacy interviewees noted the importance of having input from pharmacies and pharmacists when developing and implementing legislation and regulations.

Considerations for Covering OTC Oral Contraceptive Pills

Discussions about coverage of an OTC daily oral contraceptive pill without a prescription have barely begun at the state level. The FDA approved the daily oral contraceptive pill, Opill, for OTC use at the end of the interview fielding period. Interviewees were asked what steps, if any, they have taken in anticipation of or in reaction to FDA approval of an OTC daily oral contraceptive pill, including agency, health plan, or pharmacy discussions, or any concrete plans. For the most part, these discussions have not yet begun or are in their very early phases. Among those that have begun planning, several interviewees expressed confidence that their current system for billing for other OTC contraception such as Plan B without a prescription is a feasible way to bill for an OTC daily oral contraceptive and that they do not believe any additional steps would need to be taken to change billing and claims systems. Private health insurance plans and a state insurance department interviewed indicated that while there have been some discussions about coverage for an OTC oral contraceptive without a prescription, they have not yet taken any concrete actions. Interviewees, including a state department of insurance, mentioned the importance of involving health care providers with clinical expertise, especially pharmacists, in efforts to expand coverage. Since their interview, one state reported it has begun a provider outreach campaign to understand barriers at the pharmacy level, particularly those in smaller towns, rural areas, and tribal communities, and is developing a communications campaign to help ensure any barriers to OTC uptake are addressed by the time Opill comes to market.

The importance of clear federal guidance about any plan coverage requirements for OTC contraception was cited by many interviewees when asked for suggestions on how to best implement coverage approaches without a prescription. One interviewee from a state insurance department noted that their state relies heavily on federal action for implementing changes for new drug coverage. Representatives for a national PBM echoed that federal guidance would be helpful, and another representative for a national health plan trade group emphasized that communication related to coverage policies from the federal government needs to be clear and cannot be confusing for patients, providers, and plans. One pharmacy interviewee commented that direction from the federal government on coverage without a prescription is mutually beneficial all around. Contraceptive access advocates noted that lack of consistency in the language between what the ACA regulations require plans to cover and the tri-agency FAQs has led to differing interpretations of policy and lack of clarity on what can be enforced.

One pharmacy chain indicated that it is currently working with the U.S. Department of Health and Human Services (HHS) to try to create a payment pathway at the federal level for pharmacist prescribing, a fallback approach to coverage where coverage without a prescription is not an option.

CMS has begun preparations to accommodate coverage of OTC contraception in Medicaid, but some form of a prescription is still required to obtain federal matching funds. CMS, the federal agency that administers Medicaid in partnership with state governments/Medicaid agencies, has issued guidance on how states can leverage expanded scope of pharmacist practice to cover OTC medications such as contraception. They suggest using broad and general language in their state plan regarding Medicaid coverage of OTC drugs. States submit state plan amendments (SPAs) to CMS when they plan to make changes in how they administer Medicaid program activities and are seeking federal approval to draw down federal funds or federal matching dollars for those services.

In response to the FDA approval of OTC Narcan nasal spray in March 2023, and in anticipation of the FDA approving a daily OTC oral contraceptive, CMS has encouraged state Medicaid programs to use broad implementation language in their state plan and list which therapeutic categories are covered on their state website or other public-facing documents to prevent the need for states to submit a new SPA each time their state wishes to cover an OTC drug. For example, CMS approved SPAs from Delaware, Montana, Florida, and Illinois indicating their intent to broadly cover OTC drugs. The billing mechanisms for covering these OTC products vary by state and still require the NPI field to be filled out. CMS leaders believe that this method can be leveraged by any state because even prior to Narcan’s OTC approval, all states had a protocol in place to allow pharmacists to dispense at least some drugs, for example, through a state health official’s standing order. Some state Medicaid programs also used this approach to cover at-home COVID-19 tests.

This approach is different than state Medicaid programs using state-only funds to cover OTC contraception without a clinician’s prescription. States only receive federal matching funds for OTC contraception if it is prescribed by an authorized prescriber.

Nearly all pharmacy interviewees recommended that states considering coverage for OTC contraception should include a billing structure that adequately compensates pharmacists for their services since pharmacies are not typically paid for submitting claims for non-prescribed products.  A national PBM indicated that it is currently considering potential billing mechanisms for Opill and has begun partnering with its clients and pharmacies to effectuate this coverage. This PBM and a national PBM trade association also stressed that modernizing the pharmacy claims process and having a standardized billing process in place would facilitate the transition to covering OTC contraception such as Opill without a prescription.

Quantity limits are another consideration in coverage for OTC contraception without a prescription. Opill will be sold in packages of one-, two-, three-, and six-month supplies. Having an extended supply of oral contraception is associated with better adherence and lower rates of unintended pregnancy. Several states require plans to cover an extended supply of contraception, such as six or 12 months at a time. However, several interviewees, including some health plans and a national PBM, suggested that prohibitions on quantity limits could contribute to increased waste and costs.

While interviewees did not report these types of incidents with OTC emergency contraceptive pills, which are a closer parallel to Opill than condoms, this is an issue that at least some interviewees are thinking about in preparation for insurance coverage of Opill. On the other hand, some advocates are concerned that quantity limits can create access barriers for consumers in the event that their pack of pills gets damaged, lost, or left behind.

Stocking decisions and signage can increase opportunities for coverage. Although a few states, such as Washington and Massachusetts, require pharmacies to stock contraceptive medications such as Plan B, pharmacies in most other states will decide whether or not to carry Opill. Stocking also has implications for insurance coverage because most plans provide more coverage for drugs purchased at an in-network pharmacy than at an out-of-network pharmacy, and in some cases such as with health maintenance organizations (HMOs), drugs and services are not covered by out-of-network providers at all.

Pharmacies’ decisions on where to stock OTC contraceptives will also play a role in access, both for those with and without insurance. Some pharmacies decide to put OTC contraceptives behind the pharmacy counter or in a locked cabinet on the shelf due to shoplifting concerns. Some interviewees noted that this type of placement in a pharmacy may make it more difficult to access the contraceptives and that some consumers may have confidentiality concerns, particularly for young people and those living in smaller towns and rural areas. On the other hand, one pharmacist interviewee said that having consumers come to the pharmacy counter to obtain OTC contraception allows the pharmacist to help them understand if the product is the best option for them, understand how to use it, and assess if it is covered by their insurance.

Posting signage about the availability of OTC contraception and whether it may be covered by insurance could help increase consumer awareness and uptake. An interviewee suggested that some pharmacies may be voluntarily posting signage on the shelf where emergency contraception is stocked to inform customers that if they take the product to the pharmacy counter, the pharmacist may be able to bill insurance for it, rather than the customer having to pay for it entirely out-of-pocket. A pharmacist interviewee noted that posting this type of signage may be more difficult for chain pharmacies because they typically require upper management approval for any content that is posted in their pharmacies.

Pharmacist religious refusals can also impact access to contraception in general. Multiple interviewees in the study cited religious beliefs and refusals as common barriers to accessing hormonal contraceptives through the pharmacy in at least some parts of the state, typically in rural areas and small towns. While some health plans and pharmacies try to find a second prescribing pharmacist at the pharmacy, these refusals and objections have reportedly led to delays in patient access. Even in states where a prescription is not needed for insurance coverage of OTC contraception, a pharmacist may still refuse to process the claim.

Outreach and education to pharmacies, pharmacists, and patients will be critical in fully realizing the potential of an OTC daily oral contraceptive, as discussed by several state Medicaid programs, private health plans, pharmacists, and advocates. The insights gleaned from these interviews suggest that there is a role for a variety of stakeholders including consumer advocates, health plans, state Medicaid programs, PBMs, pharmacies, and pharmacists when it comes to informing consumers of this new product and insurance coverage for it.

Contraceptive access advocates expressed that both the availability of OTC contraceptives and having plan coverage of these products can especially benefit communities that have historically faced a myriad of barriers to accessing and affording contraception. They encourage policymakers at the state and federal level to evaluate all possible options for covering OTC contraceptives, with special attention to addressing the concerns facing communities without a pharmacy or people that experience other barriers to access.

(Back to top)

Discussion

State Policy Options

States have a variety of policy options if they seek to increase access to non-prescribed OTC contraception for individuals with private insurance. More states can continue passing laws requiring state-regulated health insurance plans to cover, without cost-sharing, OTC contraception without a prescription. Using broad language when developing laws and regulations, as some states have already done, can promote coverage of more drugs and products, such as Opill, emergency contraception, and non-hormonal methods such as condoms. Additionally, state laws requiring health plans to cover an extended supply of contraceptives, including those obtained over the counter without a prescription, could reduce burdens associated with having to order or go to the pharmacy every month. While these policies can increase opportunities for OTC contraceptive coverage for those who reside in those states, these policies only apply to those enrolled in state-regulated plans. States do not have the authority to require coverage for specific benefits in self-funded plans, which is the type of plan the majority of individuals with employer-sponsored coverage are enrolled in.

State Medicaid programs that do not currently have a SPA allowing broad coverage of OTC drugs will need to submit a SPA to CMS to cover OTC contraceptives (with a prescription). States that wish to cover Opill without a prescription for Medicaid enrollees may opt to use state-only funds. Most states that currently cover OTC contraception without a prescription for Medicaid enrollees only cover OTC emergency contraception and condoms, so policy changes would be required to permit coverage of a daily oral contraceptive pill such as Opill.

Expanding pharmacists’ scope of practice to permit them to prescribe contraception or enter into a standing order or other statewide protocol to dispense OTC contraception is another approach some states have taken. This approach still involves a prescription, but it can satisfy the prescription requirement to obtain coverage for the product and reduce some of the barriers often associated with having to obtain a prescription from a clinician.

Federal Policy Options

While state actions to increase access to non-prescribed OTC contraception without cost-sharing are meaningful for people who are eligible for that coverage, their reach is limited. The vast majority of states have not taken action to expand insurance coverage of OTC contraception without the need for a prescription. While some additional states may act on their own to develop systems and protocols to facilitate coverage of OTC methods without the need for a prescription, other states do not have the political climate to pass contraceptive coverage requirements in general, including OTC. Additionally, these coverage requirements will only apply to state-regulated health plans. Absent federal guidance or legislation, coverage requirements will continue to vary by state and by plan type.

At the federal level, in 2022, legislation was introduced in the U.S. House and Senate called the Affordability is Access Act that would require private health insurance plans to cover, without cost-sharing, FDA-approved OTC contraception purchased without a prescription. The legislation was re-introduced in 2023, shortly after the FDA advisory committees voted to recommend approval of Opill; however, its passage is unlikely in the current political climate.

Although the ACA requires most private health plans to cover, without cost-sharing, the full range of FDA-approved contraceptive methods, which includes OTC contraception, there is currently no specific requirement or policy that they be covered without a prescription. A prescription requirement is currently mentioned in federal FAQs clarifying ACA coverage requirements, with the most recent one issued by the Biden administration in July 2022. The FAQ references coverage of emergency contraception and states that plans must cover OTC contraceptives when the product is prescribed. It also states that plans are “encouraged to cover OTC emergency contraceptives with no cost-sharing when they are purchased without a prescription.” In June 2023, President Biden issued an executive order directing the U.S. Departments of Labor, Health and Human Services, and Treasury to consider new actions to improve access to affordable OTC contraception, including no-cost coverage. What those actions may look like and when they will occur is not yet known.

New federal guidance clarifying that coverage be provided with or without a prescription and without cost-sharing could have the effect of increasing access to non-prescribed OTC contraception such as Opill to the majority of people with private health insurance. Federal guidance under the preventive services contraceptive coverage requirements would apply to those in self-funded employer plans, as well as individual and other state-regulated plans and standardize OTC coverage for contraceptives across the country.

Medicaid programs, particularly for non-expansion populations, have considerable leeway in determining what benefits, including contraceptive methods, are covered. Although all state Medicaid programs cover outpatient prescription drugs, they are not required to do so. With limited exceptions (e.g., prenatal vitamins and certain tobacco cessation products), they are also not required to cover OTC drugs, but the majority of states do. CMS has indicated it could facilitate coverage of OTC contraception by approving SPAs permitting states to cover OTC drugs and products broadly. However, a prescription for OTC drugs is needed in order for the state to draw down federal matching funds. Congress would need to amend the federal Medicaid statute to require coverage of OTC products without a prescription. Absent that, states could adopt pharmacist prescribing to fulfill the prescription requirement.

Conclusion

As new products come to market through OTC availability, the issues of cost and coverage are raised by payors and consumers alike. In the case of COVID tests there was a rapid adoption of no cost coverage, but there was a national pandemic emergency and a cross cutting will from stakeholders across the spectrum to do what was possible to expand access to the tests. Currently, for insurers to pay for an OTC product, some kind of prescription is typically needed for the plan to process a claim. There is no national requirement that OTC contraceptive drugs and products be covered without a prescription, although some states and plans have moved forward to implement coverage absent a federal requirement.

There has been some level of bipartisan support for the availability of an OTC contraceptive pill, but there is less agreement about whether these methods should fall under the ACA’s no cost coverage requirement and be covered free of cost to policyholders. A policy that requires plans to cover OTC drugs without the requirement for a prescription will likely also have implications for the coverage and payment for other drugs that have OTC status beyond contraceptives and will shape the actions of plans, public programs, pharmacies, and policyholders alike.

While some of the interviewees for this project expressed that their state coverage laws for non-prescribed OTC contraception have increased access to some degree, most cited extensive challenges and confusion over the implementation of these laws. Issues cited include the mechanics of billing for a medication that is not accompanied by a prescription, lack of awareness about these laws (for health plans, pharmacists, and enrollees); and reliance on pharmacist prescribing as a fallback approach in states that allow it. From the perspective of many interviewees, these challenges have limited the impact of these coverage laws to meaningfully increase access to non-prescribed OTC contraception. Additionally, state benefit requirements only apply to fully-insured plans and do not apply to self-funded employer plans, which are only regulated by federal law.

Some interviewees expressed that uniform coverage of OTC oral contraceptives under private plans and Medicaid can only be achieved with federal action to clarify that no prescription is needed for coverage without cost-sharing. They commented on the importance for states with requirements for coverage to communicate about the availability of these benefits with health plans, pharmacies, and consumers to increase awareness and therefore access. Some interviewees noted that eliminating the prescription requirement for OTC oral contraceptives could also expand their availability, particularly to low-income individuals who may not have the resources to purchase the products directly.

The extent to which OTC contraceptive pills can broaden the availability of effective contraceptives to those who seek them will depend on many factors including state and federal policies, pharmacy engagement, public awareness and education, affordability, as well as the implementation of systems of coverage. Absent federal guidance or regulations, the availability of private insurance and Medicaid coverage of OTC contraception without a prescription will continue to depend on the state in which one lives and, if covered by employer-sponsored insurance, the plan’s funding structure.

(Back to top)

Acknowledgements

KFF thanks all of the interviewees for sharing their time, expertise, insights, and feedback throughout the course of this project. All interviewees who agreed to be identified are listed below. The authors would also like to thank Donald F. Downing (University of Washington School of Pharmacy) for his contributions to this project.

AHIP (formerly America’s Health Insurance Plans)Ashley Seyfarth, PharmD, Owner, Kare DrugCat Livingston, MD, MPH, Medical Director, Health Share of OregonChristine Gilroy, MD, Chief Medical Officer, Express ScriptsIllinois Department of Healthcare and Family ServicesJenny Arnold, PharmD, CEO, Washington State Pharmacy AssociationNew Mexico MedicaidNew York State MedicaidRobyn Elliott, Managing Partner, Public Policy PartnersSally Rafie, PharmD, Founder, Birth Control PharmacistTara Pfund, PharmD, Product Manager, AssureCareVictoria Nichols, Free the Pill Project Director, Ibis Reproductive HealthWashington State Health Care Authority

KFF staff identified states and a wide range of stakeholders that are involved in aspects of the decision-making, implementation, and oversight of coverage of OTC contraceptive methods. States were selected based on whether they had implemented insurance coverage of OTC contraception without a prescription and/or expanded the scope of pharmacist practice.

To inform interviews with Medicaid officials, KFF contracted with Health Management Associates (HMA) to assist in identifying key officials from state Medicaid programs and facilitating contact with them. HMA also provided feedback on interview guides and this analysis written by KFF, and provided clarification and guidance regarding pharmacy industry policies, processes, and terminology.

Potential interviewees were contacted by KFF or HMA via email. Follow-up emails were sent to those who did not respond. KFF consulted with several experts in the fields of pharmacy and policy to develop interview guides, which were tailored to the type of industry/agency and provided to interviewees prior to the interviews. Interviews were conducted virtually (except one that was completed in writing) by the KFF research team and lasted 30 to 60 minutes. Some interviews had multiple representatives from one agency, company, or organization, while others had a single interviewee. Interviewees representing smaller private industries and organizations were offered a $200 gift card incentive to participate.

Interviewees were asked to review the draft report and provide their feedback prior to publication, which most did.

To ensure interviewee confidentiality, interviewees were instructed that they would not be personally recognized unless given express consent. For this reason, neither interviewee names nor affiliations are included in this report.