DEERFIELD, Ill. & SAN FRANCISCO, June 13, 2023 – Walgreens is teaming up with Greater Than HIV, a public information initiative of KFF, along with health departments and community organizations, to provide free HIV testing and counseling as part of the largest National HIV Testing Day event in the nation. Hundreds of local health departments and community organizations will be at more than 400 Walgreens stores offering free, confidential and fast HIV test results. 

“This unique community-led effort brings people together in a familiar setting to receive a free HIV test, get the latest on HIV prevention and treatment and connect with local services,” said Tina Hoff, senior vice president, KFF. “Our Greater Than HIV and Walgreens National HIV Community Partnership provides a great opportunity to help people know their HIV status and take action to protect their health.” 

Click here for a list of participating Walgreens stores and hours to get a free HIV test on Tuesday, June 27. Counselors will be available to answer questions about HIV prevention and treatment options, and provide referrals for PrEP (pre-exposure prophylaxis), FDA-approved medications that are highly effective in preventing HIV. HIV test manufacturers, Abbott, BioLytical Laboratories, Inc., Chembio Diagnostics, Inc. and OraSure Technologies, Inc., donated rapid tests to support the activation. 

“Each year on National HIV Testing Day, Walgreens teams up with Greater Than HIV, KFF’s public information initiative, and community partners to provide free and confidential HIV testing and counseling at hundreds of Walgreens locations, especially in areas disproportionately impacted by HIV,” said Rick Gates, chief pharmacy officer, Walgreens. “This program builds on our local and national initiatives to reach people in community-settings so that HIV prevention and treatment options are more equitable, accessible and convenient.” 

KFF’s Greater Than HIV and Walgreens National HIV Community Partnership is an ongoing commitment to work with local health departments and community organizations to expand HIV testing and information through non-traditional settings. Since 2011, the partnership has provided more than 76,000 free HIV tests, including over 15,000 self-tests provided during the height of the COVID-19 pandemic.

Walgreens is committed to expanding testing as a critical component in ending the HIV epidemic, helping to inform individuals if they should be linked to HIV treatment services or if they qualify for PrEP. All of these tools help to prevent further transmission of HIV.

In addition to providing services to help prevent and treat HIV, Walgreens invests in training its pharmacy team members to address the specific challenges faced by people living with HIV. More than 3,000 Walgreens pharmacists are specially trained to offer one-on-one, confidential and stigma-free HIV care including medication counseling, information on prevention options and how to apply for financial assistance programs.

About Walgreens 

Walgreens (www.walgreens.com) is included in the U.S. Retail Pharmacy and U.S. Healthcare segments of Walgreens Boots Alliance, Inc. (Nasdaq: WBA), an integrated healthcare, pharmacy and retail leader with a 170-year heritage of caring for communities. WBA’s purpose is to create more joyful lives through better health. Operating nearly 9,000 retail locations across America, Puerto Rico and the U.S. Virgin Islands, Walgreens is proud to be a neighborhood health destination serving nearly 10 million customers each day. Walgreens pharmacists play a critical role in the U.S. healthcare system by providing a wide range of pharmacy and healthcare services, including those that drive equitable access to care for the nation’s underserved populations. To best meet the needs of customers and patients, Walgreens offers a true omnichannel experience, with fully integrated physical and digital platforms supported by the latest technology to deliver high-quality products and services in communities nationwide. 

About KFFKFF is the independent source for health policy research, polling, and journalism. Its mission is to serve as a nonpartisan source of information for policymakers, the media, the health policy community, and the public.  

KFF’s Greater Than HIV initiative is a leading public information response focused on HIV in the U.S. Through localized Greater Than HIV campaigns, KFF works with health departments and community partners to reach those most affected and in need with the latest on testing, prevention and treatment. This public-private partnership model helps extend the reach of limited resources in high need areas.

Introduction

Immigrants are an integral part of our nation, including our nation’s workforce. Immigrants support the U.S. economy and its workforce by filling unmet labor market needs, especially in industries such as construction and agriculture that are at increased risk of adverse health outcomes and injuries, including climate-related health hazards.^1 ,2  Through entrepreneurship and establishment of businesses, immigrants also create jobs that generate employment for other U.S. residents, including U.S.-born citizens.³  However, their employment patterns contribute to them having higher uninsured rates and facing increased health risks relative to their U.S.-born peers.⁴  While their employment patterns, in part, reflect lower educational attainment levels and skills among immigrant workers versus U.S.-born workers, research and data suggest that some immigrant workers may be overqualified for their jobs—that is having education or skills beyond what is necessary for their job.^5 ,6  Addressing this occupational mismatch could help reduce disparities in health and health care faced by immigrant families and positively benefit the U.S. economy.

This brief examines socioeconomic characteristics and employment patterns among immigrant workers and examines how they compare to U.S.-born workers, including differences among college-educated workers. It discusses the implications of these patterns for their health and well-being as well as the nation’s economy. It is based on KFF analysis of the 2022 Current Population Survey Annual Social and Economic Supplement. The analysis is limited to nonelderly adult workers between ages 19-64 who are employed either full-time or part-time in the U.S. labor force. All differences between U.S.-born and immigrant workers described in the text are statistically significant at the p<0.05 level. In sum, it finds:

• In 2021, there were 27 million immigrants employed in the labor force, making up close to one in five (17%) nonelderly adult workers (ages 19-64) in the U.S. The share of nonelderly adults who were employed was similar across U.S.-born citizens (78%), naturalized citizens (79%), and noncitizens in the U.S. for five or more years (76%), while it was 63% among recent noncitizens (in the U.S. for less than five years). Compared to their U.S.-born counterparts, nonelderly adult immigrant workers were more likely to be Hispanic or Asian, were younger, and had lower levels of educational attainment.
• Among nonelderly adults, noncitizen workers were more likely than citizen workers to be employed in construction, agricultural, and service jobs. While some of these differences in occupation patterns likely reflect lower educational levels and skills among immigrant workers, differences in occupations persisted among college-educated workers. One in ten noncitizen workers with a college degree were employed in service jobs, compared with 6% of their U.S.-born peers. College-educated noncitizen workers were also more likely than their citizen counterparts to be employed in construction and transportation jobs.
• Reflecting these differences in employment patterns, noncitizen workers were more likely than citizen workers to be low-income and uninsured, even among those with college degrees. Roughly one in three noncitizen workers was low-income (below 200% of the federal poverty level (FPL)), compared with 15% of U.S.-born workers. In addition, over three in ten nonelderly adult noncitizen workers lacked health insurance, over three times higher than the uninsured rate of their citizen counterparts, reflecting lower rates of private coverage. Incomes and coverage rates were higher among college-educated workers across citizenship statuses, but, among college-educated nonelderly adult workers, noncitizens still were more likely to be low-income and uninsured than their citizen counterparts.

Immigrant Worker Characteristics

In 2021, there were 27 million immigrants employed in the labor force, making up close to one in five (17%) nonelderly adult workers in the U.S. Roughly 8% of nonelderly workers were naturalized citizens and 9% were noncitizens, the majority of whom had been in the U.S. for five or more years (Figure 1). The share of nonelderly adults (ages 19-64) who were employed on either a full- or part-time basis was similar across U.S.-born citizens (78%), naturalized citizens (79%), and noncitizens in the U.S. for five or more years (76%), while it was 63% among recent noncitizens.

Compared to their U.S.-born counterparts, nonelderly adult immigrant workers were more likely to be Hispanic or Asian, were younger, and had lower levels of educational attainment (Figure 2).

• Among nonelderly adult workers, both naturalized citizens and noncitizen immigrants included higher shares of Hispanic and Asian adults compared to U.S.-born citizens, although the shares varied by citizenship status and length of time in the country. Over six in ten (62%) of noncitizen nonelderly adult workers in the U.S. for five years or more were Hispanic, while one in three (31%) naturalized citizens were Asian. Among more recent nonelderly noncitizen adult workers in the U.S. for less than five years, over half were Hispanic (53%) and one in five (21%) were Asian.
• Recent noncitizen nonelderly adult workers had the largest share of younger workers, with over half (55%) between 19 and 34 years of age, while those who had been in the country for five or more years and naturalized citizens had the largest share of workers between ages 35-54 (57%). Naturalized citizen nonelderly adult workers were older compared to their U.S.-born and noncitizen counterparts, with a quarter between ages 55-64.
• Roughly a quarter of noncitizen nonelderly adult workers had less than a high school education, compared to just 3% of their U.S.-born peers. However, similar proportions of nonelderly adult U.S.-born citizens (41%), naturalized citizens (47%), and recent noncitizens (44%) in the labor force had a bachelor’s degree or higher. In contrast, less than three in ten nonelderly adult noncitizen workers in the country for at least five years (29%) had at least a college degree. Research shows that an increasing number of immigrants who arrived in the U.S. in the last five years have a college degree, driven largely by an increase in the share of high-skilled immigrants arriving from Asian countries.⁷ 

Occupations Among Immigrant Workers

Among nonelderly adults, noncitizen workers were more likely than citizen workers to be employed in construction, agricultural, and service jobs. Noncitizen workers were nearly three times as likely to be employed in construction jobs compared to naturalized and U.S. born citizen workers (14% vs. 5% and 4%, respectively) (Figure 3). Moreover, one in four (25%) noncitizen workers was employed in service jobs, such as food preparation and health care support, compared with 18% of naturalized citizen and 15% of U.S.-born citizen workers. Small shares of workers were employed in agriculture across citizenship statuses, but noncitizen workers were slightly more likely to be employed in these jobs than their citizen counterparts (2% vs. less than 1%), and they accounted for 18% of all agricultural workers. They also were more likely to be employed in production and transportation jobs compared with their citizen counterparts. Occupation patterns among naturalized citizen workers were more similar to U.S.-born citizen workers, although they were more likely than their U.S.-born peers to be employed in service jobs.

While some of these differences in occupation patterns likely reflect lower educational levels and skills among immigrant workers compared with U.S.-born workers, differences in occupations persisted among workers with a college degree. Among nonelderly adult workers with a bachelor’s degree or higher, nearly half of workers were employed in professional occupations, such as accounting, engineering, and legal services, across citizenship statuses. However, one in ten noncitizen workers with a bachelor’s degree or higher were employed in service jobs such as food preparation and health care support, compared with 6% and 7% of their U.S.-born and naturalized citizen peers (Figure 4). College-educated noncitizen workers were also more likely than their citizen counterparts to be employed in construction and transportation jobs. There were no significant differences in employment in these occupations between naturalized and U.S.-born college-educated workers, although naturalized citizens were less likely than U.S-born citizens to be in management occupations (26% vs. 29%).

Income and Health Coverage among Immigrant Workers

Reflecting these differences in employment patterns, noncitizen workers were more likely than citizen workers to be low-income (income below 200% of the FPL). Nearly one in three (31%) noncitizen workers in the country for five or more years was low-income, including one in ten (9%) who had incomes below poverty (Figure 5). This share was 38% among recent noncitizen workers in the country for less than five years, including 16% with incomes below the poverty level. In contrast, 15% of U.S.-born workers were low-income, with 4% having incomes below poverty.

Incomes were higher among college-educated workers across citizenship statuses, but, among college-educated nonelderly adult workers, noncitizens were still more likely to be low-income than their citizen counterparts. Over one in ten (11%) college-educated noncitizen workers in the country for five or more years were low-income, with this share rising to 24% among college-educated recent noncitizen workers, including 10% who had incomes below the poverty level (Figure 5). In contrast, 5% of college-educated U.S.-born citizen workers were low-income, with just 1% having income below poverty.

Noncitizen nonelderly adult workers were also more likely than their citizen counterparts to be uninsured, even among those with college educations (Figure 6). Over three in ten nonelderly adult noncitizen workers lacked health insurance, over three times higher than the uninsured rate of their citizen counterparts, reflecting lower rates of private coverage among these workers. While uninsured rates were lower among college-educated workers across citizenship statuses, these differences between citizens and noncitizens persisted. Among college educated nonelderly adult workers, noncitizens were more four times as likely to lack health coverage than U.S.-born workers, with more than one in ten uninsured compared with 3% of their U.S.-born peers. This share rose to 13% among recent noncitizen workers with a college education. Medicaid coverage does not fully offset the larger gaps in private coverage for noncitizen workers, likely reflecting Medicaid eligibility restrictions for noncitizen immigrants, particularly those in the country for less than five years and for those who are undocumented, who are ineligible for any federal coverage options.⁸ 

Implications for Immigrant Health and the U.S. Workforce

Noncitizen immigrant workers are disproportionately employed in occupations with lower wages that often do not offer employer-sponsored health coverage, contributing to higher poverty and uninsured rates. The occupations in which noncitizen immigrant workers are disproportionately employed, such as service, farming, and construction jobs, also have higher adverse health risks including but not limited to climate related health risks such as heat strokes and respiratory illnesses and workplace injuries.^9 ,10  Undocumented immigrant workers may 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.¹¹ 

While some noncitizen immigrants are in lower-wage higher risk jobs due to limited experience, skills, and lack of work authorization, others may be overqualified for their positions, contributing to negative implications for immigrant families and the overall U.S. economy. This analysis finds that disparities in employment, income, and health coverage for noncitizen workers persisted among college-educated workers, suggesting some were employed in jobs for which they may be overqualified. While language barriers and work eligibility restrictions may explain part of this employment pattern, other factors such as time since immigration, age, and cultural obstacles may also play a role. Research suggests that immigrants with limited English proficiency, those who earned degrees in a country outside the U.S., and those who are recent or first-generation immigrants are more likely to experience underutilization of skills in the workplace.¹²  In addition, cultural barriers such as lack of familiarity with the U.S. labor market and lack of professional and social networks can also lead to this occupational mismatch. Beyond contributing to higher rates of poverty and uninsured rates among immigrants, this occupational mismatch can also have adverse impacts on mental health. Research suggests that working in jobs for which people may be overqualified can lead to lower rates of job as well as life satisfaction and declines in mental health.^13 ,14  A shortage of immigrant workers, including those who are college-educated, can also have a negative impact on productivity, job creation, and can consequently slow down economic growth.¹⁵  Moreover, the employment of overqualified immigrants in low-skilled jobs contributes to forgone earnings as well as tax revenues.

Actions to increase job opportunities for immigrants that fully utilize their skills could not only improve the health and well-being of immigrants but also support the economy by helping to address the country’s unmet labor market needs. Broadening pathways for migrants to enter the U.S. to fill gaps in the labor force, improving the processing of applications for work visas and work authorization, recognizing credentials for immigrant professionals, and investing in English language training for recent immigrants could benefit the U.S. economy by helping immigrants find jobs that are an appropriate match for their educational background and training.¹⁶ , ¹⁷ , ¹⁸  These actions could also support the U.S. economy by helping to fill gaps in industries experiencing the greatest shortage of workers. These include lower-skilled occupations such as manufacturing and food services, but also higher-skilled occupations such as health, professional, and business services, especially following the labor force disruptions that resulted from the COVID-19 pandemic.¹⁹  As the U.S. continues to experience workforce shortages, it is important to fully utilize the skills and potential of immigrants who form a growing share of the country’s labor market not only as workers but also as job creators.

1. The Brookings Institution (2022), “Who are the 1 million missing workers that could solve America’s labor shortages?”, https://www.brookings.edu/blog/up-front/2022/07/14/who-are-the-1-million-missing-workers-that-could-solve-americas-labor-shortages/, accessed April 5, 2023. ↩︎
2. CNN (2022), “America needs immigrants to solve its labor shortage”, https://www.cnn.com/2022/12/22/economy/immigration-jobs/index.html, accessed April 5, 2023. ↩︎
3. Northwestern University (2020), “Immigrants to the U.S. Create More Jobs than They Take”, https://insight.kellogg.northwestern.edu/article/immigrants-to-the-u-s-create-more-jobs-than-they-take, accessed April 5, 2023. ↩︎
4. KFF (2022), “Health Coverage and Care of Immigrants”, https://modern.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-and-care-of-immigrants/, accessed April 6, 2023. ↩︎
5. Forbes (2019), “Foreign-Born Workers Are Often Overqualified”, https://www.forbes.com/sites/niallmccarthy/2019/01/17/foreign-born-workers-are-often-overqualified-infographic/?sh=6b5cb8c856e7, accessed April 5, 2023. ↩︎
6. Migration Policy Institute (2016), “’Untapped Talent: The Costs of Brain Waste among Highly Skilled Immigrants in the United States”, https://www.migrationpolicy.org/sites/default/files/publications/BrainWaste-FULLREPORT-FINAL.pdf, accessed April 24, 2023. ↩︎
7. Migration Policy Institute (2020), “College-Educated Immigrants in the United States”, https://www.migrationpolicy.org/article/college-educated-immigrants-united-states, accessed April 24, 2023. ↩︎
8. University of Southern California (2023), “A Guide for Helping Immigrants and Refugees Access Health Services”, https://mphdegree.usc.edu/blog/health-insurance-for-immigrants/, accessed May 5, 2023. ↩︎
9. The National Institute for Occupational Safety and Health (2023), “Occupational Safety and Health and Climate”, https://www.cdc.gov/niosh/topics/climate/default.html, accessed April 24, 2023. ↩︎
10. U.S. Census Bureau (2017), “Workplace injuries, illnesses, and fatalities by occupation”, https://www.bls.gov/opub/ted/2017/workplace-injuries-illnesses-and-fatalities-by-occupation.htm, accessed April 24, 2023. ↩︎
11. Economic Policy Institute (2020), “Federal labor standards enforcement in agriculture”, https://www.epi.org/publication/federal-labor-standards-enforcement-in-agriculture-data-reveal-the-biggest-violators-and-raise-new-questions-about-how-to-improve-and-target-efforts-to-protect-farmworkers/?mc_cid=28c0cb58c0&mc_eid=85f0a96990, accessed April 25, 2023. ↩︎
12. Pivovarova, M., & Powers, J. M. (2022). Do immigrants experience labor market mismatch? New evidence from the US PIAAC. https://largescaleassessmentsineducation.springeropen.com/articles/10.1186/s40536-022-00127-7. Large-scale Assessments in Education, 10(1), 1-23. Accessed April 6, 2023. ↩︎
13. Johnson, G. J., & Johnson, W. R. (2000). “Perceived overqualification and dimensions of job satisfaction: A longitudinal analysis.” The Journal of psychology, 134(5), 537-555. https://www.tandfonline.com/doi/abs/10.1080/00223980009598235, accessed April 25, 2023 ↩︎
14. Chen, C., Smith, P., & Mustard, C. (2010). The prevalence of over-qualification and its association with health status among occupationally active new immigrants to Canada. https://www.tandfonline.com/doi/full/10.1080/13557858.2010.502591?casa_token=bQ_dvsNcQC8AAAAA%3A-6kg8LcCo1CiAijZv7zRYXfAjHjrPPAd5lInDqFuIW-5XH3-Jqe3F9L4k_lQpO15medsmfbhGwtlFA. Ethnicity & health, 15(6), 601-619. Accessed April 6, 2023 ↩︎
15. Peri, G., & Zaiour, R. (2022). “Labor shortages and the immigration shortfall”, https://econofact.org/labor-shortages-and-the-immigration-shortfall, accessed April 18, 2023. ↩︎
16. Migration Policy Institute (2022), “Unblocking the U.S. Immigration System: Executive Actions to Facilitate the Migration of Needed Workers”, https://www.migrationpolicy.org/sites/default/files/publications/mpi-global-skills-us-executive-actions-2023_final.pdf, accessed April 6, 2023. ↩︎
17. Migration Policy Institute (2023), “What Role Can Immigration Play in Addressing Current and Future Labor Shortages?”, https://www.migrationpolicy.org/sites/default/files/publications/mpi-global-skills-labor-shortages-brief-2023_final.pdf, accessed April 18, 2023. ↩︎
18. Society for Human Resource Management (2021), “English Classes Help Retain Immigrant Workers”, https://www.shrm.org/hr-today/news/all-things-work/pages/english-classes-help-retain-immigrant-workers.aspx, accessed April 6, 2023. ↩︎
19. U.S. Chamber of Commerce (2023), “Understanding America’s Labor Shortage: The Most Impacted Industries”, https://www.uschamber.com/workforce/understanding-americas-labor-shortage-the-most-impacted-industries, accessed April 18, 2023. ↩︎

1. Medicaid enrollment increased since the start of the pandemic, primarily due to the continuous enrollment provision.
2. KFF estimates that between 8 million and 24 million people will lose Medicaid coverage during the unwinding of the continuous enrollment provision.
3. The Medicaid continuous enrollment provision stopped “churn” among Medicaid enrollees.
4. States approaches to unwinding the continuous enrollment provision vary.
5. Maximizing streamlined renewal processes can promote continuity of coverage as states unwind the continuous enrollment provision.
6. States have obtained temporary waivers to pursue strategies to support their unwinding plans.
7. Certain groups may be at greater risk of losing Medicaid coverage during the unwinding period.
8. States can partner with MCOs, community health centers, and other partners to conduct outreach.
9. Timely data on disenrollments and other metrics will be useful for monitoring how the unwinding is proceeding.
10. The number of people without health insurance could increase if people who lose Medicaid coverage are unable to transition to other coverage.

At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which included a requirement that Medicaid programs keep people continuously enrolled through the end of the COVID-19 public health emergency (PHE), in exchange for enhanced federal funding. As part of the Consolidated Appropriations Act, 2023, signed into law on December 29, 2022, Congress delinked the continuous enrollment provision from the PHE, ending continuous enrollment on March 31, 2023.  The CAA also phases down the enhanced federal Medicaid matching funds through December 2023. Primarily due to the continuous enrollment provision, Medicaid enrollment has grown substantially compared to before the pandemic and the uninsured rate has dropped. During the unwinding of the continuous enrollment provision, millions of people are expected to lose Medicaid and that could reverse recent gains in coverage, though not everyone who loses Medicaid will become uninsured. States could begin disenrolling people starting in April, but many did not resume disenrollments until May, June, or July. To be eligible for enhanced federal funding during the unwinding, states must meet certain requirements. To date, as reported in the KFF Medicaid Enrollment and Unwinding Tracker, there is wide variation in the number of people who have been disenrolled and in disenrollment rates across states with publicly available data.

This brief describes 10 key points about the unwinding of the Medicaid continuous enrollment provision, highlighting data and analyses that can inform the unwinding process as well as legislation and guidance issued by the Centers for Medicare and Medicaid Services (CMS) that lay out the rules states must follow during the unwinding period and the flexibilities available to them.

1. Medicaid enrollment increased since the start of the pandemic, primarily due to the continuous enrollment provision.

KFF estimates that enrollment in Medicaid/CHIP enrollment will have grown by 23.3 million to nearly 95 million from February 2020 to the end of March 2023, when the continuous enrollment provision ended (Figure 1). Overall enrollment increases reflect economic conditions related to the pandemic, the adoption of the Medicaid expansion under the Affordable Care Act in several states (NE, MO, OK), as well as the continuous enrollment provision included in the FFCRA. This provision requires states to provide continuous coverage for Medicaid enrollees in order to receive enhanced federal funding. By preventing states from disenrolling people from coverage, the continuous enrollment provision has helped to preserve coverage during the pandemic. It also increased state spending for Medicaid, though KFF has estimated that the enhanced federal funding from a 6.2 percentage point increase in the federal match rate (FMAP) exceeded the higher state costs through 2022.

The Consolidated Appropriations Act, 2023 decoupled the Medicaid continuous enrollment provision from the PHE and terminated this provision on March 31, 2023. Starting April 1, 2023, states could resume Medicaid disenrollments. States will be eligible for the phase-down of the enhanced FMAP (6.2 percentage points through March 2023; 5 percentage points through June 2023; 2.5 percentage points through September 2023 and 1.5 percentage points through December 2023) if they comply with certain rules. They cannot restrict eligibility standards, methodologies, and procedures and cannot increase premiums as required in FFCRA. Further, states must also comply with federal rules about conducting renewals. Lastly, states are required to maintain up to date contact information and attempt to contact enrollees prior to disenrollment when mail is returned.

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2. KFF estimates that between 8 million and 24 million people will lose Medicaid coverage during the unwinding of the continuous enrollment provision.

While the number of Medicaid enrollees who may be disenrolled during the unwinding period is highly uncertain, KFF estimates that between 7.8 million and 24.4 million people could lose Medicaid coverage during the 12-month unwinding period reflecting an 8% and 28% decline in enrollment (Figure 2). If Medicaid enrollment decreased by 18%, the midpoint of the range, 17 million people would lose Medicaid coverage. These projected coverage losses are consistent with estimates from the Department of Health and Human Services (HHS) suggesting that as many as 15 million people will be disenrolled, including 6.8 million who will likely still be eligible. Findings from a survey of Medicaid enrollees fielded just prior to the start of the unwinding period suggest that many people who will be disenrolled in the coming months may continue to be eligible. While most enrollees were unaware that states are permitted to resume disenrollments suggesting they may not know that they will need to renew their coverage in the coming months, nearly two-thirds of enrollees said they have not had a change in income or circumstance that would make them ineligible for Medicaid.

While the share of individuals disenrolled across states will vary due to differences in how states prioritize renewals, it is expected that the groups that experienced the most growth due to the continuous enrollment provision—ACA expansion adults, other adults, and children—will experience the largest enrollment declines. Efforts to conduct outreach, education and provide enrollment assistance can help ensure that those who remain eligible for Medicaid are able to retain coverage and those who are no longer eligible can transition to other sources of coverage.

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3. The Medicaid continuous enrollment provision  stopped “churn” among Medicaid enrollees.

The temporary loss of Medicaid coverage in which enrollees disenroll and then re-enroll within a short period of time, often referred to as “churn,” occurs for a several reasons. Enrollees may experience short-term changes in income or circumstances that make them temporarily ineligible. Alternatively, some people who remain eligible may face barriers to maintaining coverage due to renewal processes and periodic eligibility checks. Eligible individuals are at risk for losing coverage if they do not receive or understand notices or forms requesting additional information to verify eligibility or do not respond to requests within required timeframes. Churn can result in access barriers as well as additional administrative costs. Estimates indicate that among full-benefit beneficiaries enrolled at any point in 2018, 10.3% had a gap in coverage of less than a year (Figure 3). About 4.2% were disenrolled and then re-enrolled within three months and 6.9% within six months. Another analysis examining a cohort of children newly enrolled in Medicaid in July 2017 found that churn rates more than doubled following annual renewal, signaling that many eligible children lose coverage at renewal. By halting disenrollment during the PHE, the continuous enrollment provision has also halted this churning among Medicaid enrollees. Seven states have waivers approved (6) or pending (1) to allow for guaranteed continuous enrollment beyond what is allowed under current law, including approvals in Washington and Oregon to guarantee Medicaid coverage for children through age six.

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4. State approaches to unwinding the continuous enrollment provision vary.

States are taking different approaches to unwinding the continuous enrollment provision. CMS requires states to submit renewal redistribution plans that describe how the state will prioritize renewals, how long the state plans to take to complete the renewals as well as the processes and strategies the state is considering or has adopted to reduce inappropriate coverage loss during the unwinding period. As of May 9, 2023, 30 states had posted their renewal redistribution plan, which had to be submitted to CMS by February 15, 2023 for most states. Differences in state renewal and other policies and in how they implement those policies are likely to lead to differences across states in the extent of Medicaid enrollment declines during the unwinding period.

According to a KFF survey conducted in January 2023, states have taken a variety of steps to prepare for the end of the continuous enrollment provision (Figure 4). Under CMS guidance, states had the option to start the unwinding period by initiating the first batch of renewals in February, March, or April. Eight states started the process in February, another 15 started in March, and 28 states began in April. Most states (43) said they plan to take 12-14 months to complete all renewals (the remaining eight states said they planned to take less than 12 months to complete renewals). All states indicated they had taken steps to update enrollee contact information during the past year and nearly three-quarters of states (38) were planning to follow up with enrollees who do not respond to a renewal request before terminating coverage.

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5. Maximizing streamlined renewal processes can promote continuity of coverage as states unwind the continuous enrollment provision.

Under the ACA, states must seek to complete administrative (or “ex parte”) renewals by verifying ongoing eligibility through available data sources, such as state wage databases, before sending a renewal form or requesting documentation from an enrollee. Some states suspended renewals as they implemented the continuous enrollment provision and made other COVID-related adjustments to operations. Completing renewals by checking electronic data sources to verify ongoing eligibility reduces the burden on enrollees to maintain coverage. While 31 states have taken action in the past year to increase ex parte renewal rates, in many states, the share of renewals completed on an ex parte basis is low. Although states were not required to process ex parte renewals while the continuous enrollment provision was in place, of the 43 states that were processing ex parte renewals for MAGI groups (people whose eligibility is based on modified adjusted gross income) in January 2023, 18 states reported completing 50% or more of renewals using ex parte processes. Twenty states completed less than 50% of renewals on an ex parte basis, including 11 states where less than 25% of renewals were completed using ex parte processes (Figure 5). The number of states reporting they complete more than 50% of renewals using ex parte processes for non-MAGI groups (people whose eligibility is based on being over age 65 or having a disability) is even lower at 6.

As states begin to unwind the continuous enrollment provision, there are opportunities to promote continuity of coverage among enrollees who remain eligible by increasing the share of renewals completed using ex parte processes and taking other steps to streamline renewal processes (which will also tend to increase enrollment and spending). CMS guidance notes that states can increase the share of ex parte renewals they complete without having to follow up with the enrollee by expanding the data sources they use to verify ongoing eligibility. However, when states do need to follow up with enrollees to obtain additional information to confirm ongoing eligibility, they can facilitate receipt of that information by allowing enrollees to submit information by mail, in person, over the phone, and online. While nearly all states accept information in-person (51 states) and by mail (50 states), slightly fewer provide options for individuals to submit information online (48 states) or over the phone (46 states).

A proposed rule, released on September 7, 2022, seeks to streamline enrollment and renewal processes in the future by applying the same rules for MAGI and non-MAGI populations, including limiting renewals to once per year, prohibiting in-person interviews and requiring the use of prepopulated renewal forms. Overall, every state has taken at least one action to align renewal processes for non-MAGI populations with those for MAGI populations, including 45 states that have eliminated in-person interviews, 42 states that limit renewals to once per year, and 33 states that send pre-populated renewal forms.(Back to top)

6. States have obtained temporary waivers to pursue strategies to support their unwinding plans.

As states prepare to complete redeterminations for all Medicaid enrollees, many may face significant operational challenges related to staffing shortages and outdated systems. To reduce the administrative burden on states, CMS announced the availability of temporary waivers through Section 1902(e)(14)(A) of the Social Security Act. These waivers will be available on a time-limited basis and will enable states to facilitate the renewal process for certain enrollees with the goal minimizing procedural terminations. As of February 24, 2023, CMS had approved a total of 188 waivers for 47 states (Figure 6). These waivers include strategies allowing states to: renew enrollee coverage based on SNAP and/or TANF eligibility; allow for ex parte renewals of individuals with zero income verified within the past 12 months; allow for renewals of individuals whose assets cannot be verified through the asset verification system (AVS); partner with managed care organizations (MCOs), enrollment brokers, or use the National Change of Address (NCOA) database or US postal service (USPS) returned mail to update enrollee contact information; extend automatic enrollment in MCO plans up to 120 days; and extend the timeframe for fair hearing requests.

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7. Certain groups may be at greater risk of losing Medicaid coverage during the unwinding period.

As states resume redeterminations and disenrollments, certain individuals, including people who have moved, immigrants and people with limited English proficiency (LEP), people with disabilities, and older adults, will be at increased risk of losing Medicaid coverage or experiencing a gap in coverage due to barriers completing the renewal process, even if they remain eligible for coverage. Enrollees who have moved may not receive important renewal and other notices, especially if they have not updated their contact information with the state Medicaid agency. In 2020, one in ten Medicaid enrollees moved in-state and while shares of Medicaid enrollees moving within a state has trended downward in recent years, those trends could have changed in 2021 and 2022.

An analysis of churn rates among children found that while churn rates increased among children of all racial and ethnic groups, the increase was largest for Hispanic children, suggesting they face greater barriers to maintaining coverage. Additionally, people with LEP and people with disabilities are more likely to encounter challenges due to language and other barriers accessing information in needed formats. An analysis of state Medicaid websites found that while a majority of states translate their online application landing page or PDF application into other languages, most only provide Spanish translations (Figure 7). That same analysis revealed that a majority of states provide general information about reasonable modifications and teletypewriter (TTY) numbers on or within one click of their homepage or online application landing page, but fewer states provide information on how to access applications in large print or Braille or how to access American Sign Language interpreters.

Older adults may also be at higher risk of losing coverage during the unwinding period. Early findings from a survey of health insurance consumers found that two-thirds of older Medicaid enrollees reported they had not previously participated in a renewal of their Medicaid coverage (Figure 8). Enrollees who do not have experience actively renewing Medicaid coverage may be less prepared for what to expect when their eligibility is redetermined in the coming months, lessening their ability to navigate and complete the renewal process. Additionally, nearly half of older Medicaid enrollees provided updated contact information to the state Medicaid agency compared to just a third of Medicaid enrollees overall.

CMS guidance about the unwinding of the continuous enrollment provision stresses the importance of conducting outreach to enrollees to update contact information and provides strategies for partnering with other organizations to increase the likelihood that enrollee addresses and phone numbers are up to date. CMS guidance also outlines specific steps states can take, including ensuring accessibility of forms and notices for people with LEP and people with disabilities and reviewing communications strategies to ensure accessibility of information. Ensuring accessibility of information, forms, and assistance will be key for preventing coverage losses and gaps among these individuals.(Back to top)

8. States can partner with MCOs, community health centers, and other partners to conduct outreach.

States can collaborate with health plans and community organizations to conduct outreach to enrollees about the need to complete their annual renewal during the unwinding period. CMS has issued specific guidance allowing states to permit MCOs to update enrollee contact information and facilitate continued enrollment. According to a survey of non-profit, safety net health plans that participate in Medicaid, a majority of responding MCOs reported that they are sending updated member contact information to their state. Additionally, nearly two-thirds of states (33) are planning to send MCOs advance lists of members for whom the state is initiating the renewal process and about half will send lists of members who have not submitted renewal forms and are at risk of losing coverage or who have been disenrolled indicating whether the member was determined no longer eligible or disenrolled for paperwork reasons (Figure 9).

States can also work with community health centers, navigators and other assister programs, and community-based organizations to provide information to enrollees and assist them with updating contact information, completing the Medicaid renewal process, and transitioning to other coverage if they are no longer eligible. A survey of health centers conducted in late 2021 found that nearly 50% of responding health centers reported they have or plan to reach out to their Medicaid patients with reminders to renew their coverage and to schedule appointments to assist them with renewing coverage. Similarly, a survey of Marketplace assister programs found that assister programs were planning a variety of outreach efforts, such as public education events and targeted outreach in low-income communities, to raise consumer awareness about the end of the continuous enrollment provision. Additionally, nearly six in ten assister programs said they had proactively reached out to their state to explore ways to help consumers; supported the state sharing contact information with them on individuals who need to renew their Medicaid coverage; and were planning to recontact Medicaid clients to update their contact information. Connecting Medicaid enrollees with assister programs could help people navigate the renewal process; a large majority of Medicaid enrollees say having a state expert help them with the process of renewing their Medicaid coverage and looking for other coverage, if needed, would be useful.(Back to top)

9. Timely data on disenrollments and other metrics will be useful for monitoring how the unwinding is proceeding.

As part of a broad set of unwinding reporting requirements, states provided baseline data at the start of the unwinding period and then will submit monthly reports that will be used to monitor unwinding metrics through June 2024 (Figure 10). Through the monthly reports, states are reporting total renewals due in the reporting month, the number of enrollees whose coverage was renewed, including via ex parte processes, the number of enrollees who were determined ineligible and disenrolled, the number of enrollees disenrolled for procedural reasons, and the number of renewals that remain pending.

The  Consolidated Appropriations Act included additional reporting requirements for states and requires that CMS make the data reported by states publicly available (Figure 10). The legislation also imposes penalties in the form of reduced federal matching payments for states that do not comply with the reporting requirements. States that do not report the required data face a reduction in federal medical assistance percentage (FMAP) of up to one percentage point for the quarter in which the requirements are not met. If CMS determines a state is out of compliance with any applicable redetermination and reporting requirements, it can require the state to submit a corrective action plan and can require the state to suspend all or some terminations for procedural reasons until the state takes appropriate corrective action.

Collectively, these metrics are designed to demonstrate states’ progress towards restoring timely application processing and initiating and completing renewals of eligibility for all Medicaid and CHIP enrollees and can assist with monitoring the unwinding process to identify problems as they occur. However, while the new data reporting requirements are useful, they will not provide a complete picture of how the unwinding is proceeding and whether certain groups face barriers to maintaining coverage. To fully assess the impact of the unwinding will require broader outcome measures, such as continuity of coverage across Medicaid, CHIP, Marketplace, and employer coverage, gaps in coverage over time, and increases in the number of the uninsured, data that will not be available in the short-term.

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10. The number of people without health insurance could increase if people who lose Medicaid coverage are unable to transition to other coverage.

The share of people who lack health insurance coverage dropped to 8.6% in 2021, matching the historic low in 2016, largely because of increases in Medicaid coverage, and to a lesser extent, increases in Marketplace coverage. However, as states resume Medicaid disenrollments, these coverage gains are likely to be reversed. The Congressional Budget Office (CBO) projects that 6.2 million people who are disenrolled from Medicaid over the next 18 months will become uninsured, and that the uninsured rate will increase to 10.1% by 2033. CMS guidance provides a roadmap for states to streamline processes and implement other strategies to reduce the number of people who lose coverage even though they remain eligible. However, there will also be current enrollees who are determined to be no longer be eligible for Medicaid, but who may be eligible for ACA marketplace or other coverage. A MACPAC analysis examined coverage transitions for adults and children who were disenrolled from Medicaid or separate CHIP (S-CHIP) and found that very few adults or children transitioned to federal Marketplace coverage, only 21% of children transitioned from Medicaid to S-CHIP, while 47% of children transitioned from S-CHIP to Medicaid (Figure 11).

A KFF analysis revealed that among people disenrolling from Medicaid, roughly two-thirds (65%) had a period of uninsurance in the year following disenrollment, and only 26% enrolled in another source of coverage for the full year following disenrollment (Figure 12). Together, these findings suggest that individuals face barriers moving from Medicaid to other coverage programs, including S-CHIP. Simplifying those transitions to reduce the barriers people face could help ensure people who are no longer eligible for Medicaid do not become uninsured. Importantly, these findings also show that large shares of enrollees (41% in the KFF analysis) reenroll in Medicaid after a period of time, and many after a period of uninsurance. Reducing the number of people who lose coverage for procedural reasons even though they remain eligible can also help to reduce the number of people who become uninsured

The proposed eligibility and enrollment rule aims to smooth transitions between Medicaid and CHIP by requiring the programs to accept eligibility determinations from the other program, to develop procedures for electronically transferring account information, and to provide combined notices. States can also consider sharing information on consumers losing Medicaid who may be eligible for Marketplace coverage with Marketplace assister programs; however, in a 2022 survey, few assister programs (29%) expected states to provide this information although nearly half were unsure of their state’s plans.

What do the early data show?

As states begin to unwind the COVID emergency continuous enrollment provision and resume Medicaid disenrollments, early data from a handful of states – highlighted on KFF’s regularly-updated Medicaid Enrollment and Unwinding Tracker – reveal wide variation in disenrollment rates. While not all states that have resumed disenrollments have publicly posted their numbers, data from 12 states show that over half a million enrollees have already been disenrolled, nearly 250,000 in Florida alone (Figure 1). In nine states that reported both total completed renewals and total disenrollments, the disenrollment rate ranges from 54% in Florida to just 10% Virginia. Among these states, the median disenrollment rate is 34.5%.

The early data also reveal high rates of procedural disenrollments in some states reporting this break out. The share of procedural disenrollments – where people are disenrolled because they did not complete the enrollment process and may or may not still be eligible for Medicaid – exceeds 80% in Arkansas, Indiana, Florida and West Virginia, and was nearly 55% in Iowa (Figure 2). High procedural disenrollments raise concerns particularly in light of recent findings from a KFF survey that nearly two-thirds of current Medicaid enrollees said they did not have a change in income or circumstance in the past year that would make them ineligible for Medicaid. While it is possible that some people are not completing the renewal process because they have other coverage, the survey findings suggest many of the people whose coverage was terminated for procedural reasons in the past month likely remain eligible.

What are key questions to ask as more data become available?

These early data provide an important, but incomplete, picture of how the unwinding is unfolding across the states that have so far resumed disenrollments. Although CMS requires states to report monthly data on total renewals due, total individuals whose coverage was renewed, and total disenrollments, including for procedural reasons, only a handful of states have so far released these reports publicly. Other states have created dashboards, but the data states are reporting vary. In some cases, data are only for a subset of the total Medicaid populations or disenrollments are reported but without breakouts for procedural disenrollments. Having more consistent data from all states would help provide a clearer picture of how the unwinding is unfolding across states.

Is variation in how states are prioritizing renewals driving early differences in disenrollment rates?  In some states, including Arkansas, Idaho, Iowa, and Florida, early renewals are largely among people the states think are no longer eligible or who did not respond to renewal requests while the continuous enrollment provision was in place; these states generally have higher disenrollment rates compared to other states (except for Iowa). Other states, like Indiana, Nebraska, and Virginia, have instead adopted a time-based approach where they conduct renewals based on an individual’s renewal date. And still other states, such as Arizona, are including a mix of people they think are no longer eligible along with those whose scheduled renewal date is in the reporting month. State renewal policies and systems capacity may also play a role in the variation in disenrollment rates.

How can state communication and outreach efforts be improved to lower the rates of procedural disenrollments?  Despite broad efforts by many states to reach out to Medicaid enrollees in advance of the start of the unwinding, the messages may not have gotten through. The KFF survey findings also reveal that nearly two-thirds of Medicaid enrollees are not aware that states are now permitted to resume disenrolling people from the Medicaid program. In addition, nearly half said they had not previously actively participated in renewing their Medicaid coverage. Consequently, many enrollees may not know what to expect or how to complete the renewal process, which may be contributing to the high rates of procedural disenrollments in some states. States can continue to conduct outreach and engage more fully with key stakeholders to raise awareness throughout the unwinding period.

Will there be any way to track whether people who are disenrolled but remain eligible are able to reenroll in Medicaid? With such high disenrollment rates for procedural reasons, it is likely that some, possibly many, people who lose coverage continue to qualify for Medicaid. Some of these people may churn back onto the Medicaid program, but others may not regain coverage. Research indicates that about 10% of Medicaid enrollees churn in a normal year, while another analysis focused on children found that disenrollment and churn are higher at annual renewal. Moreover, most people who lose Medicaid coverage experience a period of uninsurance before reenrolling in Medicaid. Right now, however, only Pennsylvania appears to be tracking and reporting whether people who are disenrolled reenroll in Medicaid within four months.

Are any states providing data about what happens to individuals who are determined ineligible? There is also the question of whether people who are disenrolled because they are no longer eligible are able to obtain other coverage, particularly through the ACA Marketplaces, though potentially through employers as well. The Consolidated Appropriations Act requires states to report on the number of people who are transferred to the Marketplace and how many people enroll in a QHP. States that operate their own Marketplaces can provide this information, but so far, only Kentucky and Pennsylvania include this information on their state dashboards while Rhode Island reports the data will be included once it’s available. CMS has indicated that the Federal Marketplace, Healthcare.gov, will provide data for the 33 states that use the FFM; however, it is not clear when any data will be released.

How will states and CMS respond to early data? Some states are taking steps to minimize procedural disenrollments. For example, Idaho paused procedural disenrollments in April because of a technical issue and Iowa is holding open cases to do a “safety check” to ensure that they don’t overlook any documents that have been submitted. How CMS will respond remains uncertain. The agency is working with states to address compliance issues and it does have the authority to require states to pause procedural disenrollments if states do not take corrective action to address compliance issues.

These data raise concerns and signal that outreach to Medicaid enrollees throughout the renewal process could help reduce the rate of procedural disenrollments. However, more months of data may be needed to assess whether there are fundamental problems with how some states are conducting these renewals or whether these high disenrollment rates were temporary and will moderate over time. In the months ahead, it will also be important to continue to examine how variation in policies and implementation of unwinding is affecting disenrollments.

Updated on May 30, 2023 to reflect South Dakota’s state plan amendment submissionWith the end of the Medicaid continuous enrollment provision that was implemented during the pandemic health emergency, states are resuming Medicaid disenrollments. Many individuals who originally qualified for Medicaid through pregnancy eligibility may be at risk of losing coverage. During the pandemic, people who obtained Medicaid coverage because they were pregnant were able to remain on the program even after the traditional 60-day postpartum coverage period ended. CMS data show that from February 2020 to July 2022 there was a 75% increase in enrollment in the pregnancy eligibility group. States could have moved people to other eligibility groups, but many did not.

While the Medicaid continuous enrollment was in place, Congress took additional steps to improve postpartum coverage by giving states the option to extend that coverage from 60 days to 12 months starting in April 2022. Because this coverage option has not been uniformly adopted by states, some postpartum individuals may now be disenrolled after 60 days as states return to pre-pandemic enrollment and eligibility operations.

State policies on postpartum coverage

Medicaid offers coverage to pregnant women and others with state established income eligibility levels that range from 138% to 380% of poverty (ranging from approximately $34,000 to $94,000 annually for a family of 3), and as a result, covers four in ten births nationally. States must cover pregnant people through 60 days postpartum, and now have the option to extend that coverage to 12 months. In addition to state choices to implement the postpartum extension, states’ policies on full Medicaid expansion affect coverage in the postpartum period. Prior to the pandemic, in expansion states, most women and people eligible for postpartum coverage who had incomes up to 138% FPL could stay on the program, and many with higher incomes could qualify for subsidized coverage through the Affordable Care Act (ACA) Marketplace. However, in states that had not adopted Medicaid expansion, eligibility levels for parents are much lower than for pregnancy, so many people would lose coverage after 60 days because their incomes exceeded the lower income thresholds for parents. Those with incomes below poverty – which is the minimum income required to qualify for ACA subsidies – were caught in the “Medicaid coverage gap” in non-expansion states.

It is well accepted that the postpartum period extends beyond 60 days. Many common pregnancy-related complications, such as cardiovascular conditions, hypertension, and postpartum depression require care over a longer-term. Providing coverage for a longer period after pregnancy also promotes continuity of care and access to preventive services such as contraception and intrapartum care. Since the pandemic’s onset, there has been a sea change in postpartum coverage as 38 states and DC have adopted the 12-month extension and another 4 states have legislation to adopt the extension pending (Figure 1).

Over the coming months, across the states that have not adopted the 12-month postpartum extension, people who qualified for Medicaid through the pregnancy pathway risk losing Medicaid coverage before the end of their postpartum year because pregnancy-related income eligibility levels are higher than those for parents. However, the risk is greater in some non-expansion states. Texas, for example, has not expanded Medicaid under the ACA and does not have an approved postpartum extension (state legislators are considering a bill). A single mother with a newborn in Texas may lose Medicaid coverage two months after giving birth if she has an annual income above $4,000 (~16% of the poverty level). Furthermore, she may fall into the coverage gap if her income is below the poverty line ($24,860), the minimum eligibility for assistance through the ACA marketplace.

Considerations for Unwinding

As states resume Medicaid disenrollments, many who qualified for Medicaid through the pregnancy pathway during the pandemic are at risk of losing Medicaid coverage. Some will qualify for subsidized ACA Marketplace plans. Some parents, particularly in non-expansion states, are likely to become uninsured, but their children will remain eligible for Medicaid or CHIP.

Some postpartum individuals may also lose coverage despite remaining eligible because they face barriers to completing the renewal process. Not receiving or understanding renewal notices or not knowing how to respond to state requests for information are some of the reasons why people may not complete the renewal process.

Monitoring how the Medicaid unwinding is proceeding in states can help ensure continuity of coverage for eligible postpartum individuals by identifying potential enrollment problems early in the process. States are required to report monthly on the number of individuals with pregnancy-related coverage who are terminated and whether it is for procedural reasons; however, data collection, quality and timing may be a challenge.

The demands of caring for a newborn can exacerbate challenges in completing the renewal process, which is further complicated because infants born during the pandemic will need to transition to eligibility for children, another procedural hurdle for parents of young children. State approaches to the unwinding process, particularly policies to streamline renewals and to follow up with enrollees who have not completed the renewal process, can facilitate the ability of eligible individuals to retain coverage.

Introduction

In the wake of COVID-19, the world has a new global health, multilateral financing mechanism known as the Pandemic Fund. Based at the World Bank, and officially launched in November 2022, it is the first mechanism with the specific purpose of providing sustained financing to help countries build their capacity to prevent, prepare for, and respond to epidemics and pandemics. While there had been discussions for years about increasing the amount of multilateral financing (i.e., donor funding channeled through an intergovernmental entity) directed to pandemic preparedness, it wasn’t until COVID-19 that policymakers and donors were spurred into action to create a formal mechanism for this purpose. The U.S. government has been a key champion of the Pandemic Fund since President Biden came into office in 2021 and the U.S. has provided more funding than any other donor up to this point.

Given how nascent the fund is, there are still many unknowns and unanswered questions about how it will be implemented, the scope and duration of its work, and how it fits into the broader set of global health efforts. To help shed light on these topics, this brief reviews the evolution and establishment of the Pandemic Fund, describes the Fund’s governance and operations, and discusses key issues and challenges for the Fund – particularly related to U.S. engagement – as it continues to make its transition from concept to implementation.

History and Development

There have long been calls for increased global cooperation and more international funding for building pandemic preparedness and response (PPR) capabilities worldwide. In 2005, World Health Organization (WHO) member states agreed to a revised set of rules for prevention of and response to international health crises, known as the International Health Regulations (IHRs) and, among other things, committed to build up core capacities for PPR. However, progress toward meeting established capacity benchmarks was slow and led to efforts to direct more attention and funding to PPR, such as the establishment of the Global Health Security Agenda in early 2014, just before the emergence of the largest Ebola outbreak in history. As a result, numerous expert commissions, panels, and international institutions pointed again to significant weaknesses in global PPR capabilities and recommended greater international coordination and increased funding. While a few incremental changes were enacted post-Ebola, it was clear that major gaps in PPR capabilities worldwide remained and funding was limited compared to estimated need. Even before COVID-19 emerged, some experts were already calling for increased multilateral funding for PPR including through multilateral development banks like the World Bank.

When COVID-19 precipitated a worldwide crisis starting in 2020, broader interest in multilateral PPR funding was re-ignited. Reports from high level international panels and expert commissions such as the G20 Joint Task Force and the Independent Panel for Pandemic Preparedness and Response recommended increased funding and using multilateral development banks to channel additional support for PPR. Endorsements and support for the idea of a “financial intermediary fund” (FIF) for PPR came from the Biden White House, the WHO Director-General, the European Union, and many other policymakers, organizations, and experts. In April 2022, G20 finance ministers agreed to establish such a fund and in June 2022, the World Bank approved the creation of a “financial intermediary fund for pandemic preparedness and response (FIF).” The FIF was formally established in September 2022, and officially launched as the renamed “Pandemic Fund” in November 2022 (see Box 1 for a fuller timeline of events in the development of the Pandemic Fund).

The decision to house the Fund at the World Bank reflected the Bank’s role in hosting similar mechanisms. While the Pandemic Fund is the first FIF focused on PPR specifically, there are at least two dozen other FIFs hosted by the World Bank, including a number of other global health-focused FIFs such as the Coalition for Epidemic Preparedness Innovations (CEPI), the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, and the Global Finance Facility for Women, Children and Adolescents. Each FIF has its own unique rules and approaches to governance, financing, implementation, funding amounts, and other characteristics.

Mission, Governance, and Operations

The Fund has only recently been officially launched, and details of how it is governed and how it operates have had to be crafted over a relatively compressed time period. Stakeholders including donors, beneficiary governments, international agencies such as the WHO and World Bank, and civil society groups have all helped shape these details since mid-2022, and some aspects continue to evolve as the Fund moves further into its implementation phase. Several documents have been released by the World Bank and the Fund to describe how it works, including: a Board paper on establishing the Fund, a Governance Framework, and an Operations Manual. The Fund also released its first Call for Proposals, which outlines in more detail the process for submission, review, and distribution of funding.

This section summarizes publicly available information about the Fund’s governance and operations, and reviews key issues and debates that emerged as policies were developed.

Mission

According to the Governance Framework, the primary objective of the Fund is to “provide a dedicated stream of additional, long-term funding for critical pandemic PPR functions” to support and reinforce existing capacity building efforts. More specifically, the Fund is designed to add value by: 1) mobilizing additional sources of financing, including philanthropic and private sector funding more broadly, 2) leveraging its resources to incentivize more spending via matching domestic resources, co-financing and/or “concessional” lending, and 3) harmonizing spending for PPR and health systems by bringing actors together and linking financing with country level planning and prioritization processes.

As the Fund was being developed, the importance of this additionality was emphasized frequently. Rather than being another vehicle to re-direct existing government donor financing to global health security, the Fund is meant to draw in funding that would not otherwise be available and use its funding in such a way to encourage more spending by domestic governments and the private sector on pandemic preparedness activities.

Financial Status

As of May 22, 2023, 26 donors (including countries, philanthropic foundations, and non-profit organizations) had pledged an estimated total of $1.9 billion in support of the Pandemic Fund, some of which consists of future commitments. The total amount received from donors and available for use (as of May 22, 2023) is reported as $1.1 billion, $300 million of which is dedicated to funding projects resulting from the first call for proposals.

The three largest donors to date by total amount committed (including paid and unpaid funds) are: the U.S. ($700 million), European Commission/European Union (EU/EC, $464 million), and Germany ($123 million). Counting only amounts paid in, the three largest donors so far are the United States ($450 million), the EU/EC ($248 million), and Italy ($106 million). Figure 1 shows a list of donor paid and unpaid contributions, by paid in amounts.

Governance

Policymakers faced many questions and debates about how to structure the Fund’s governing bodies to ensure some balance in decision-making and oversight between donors, international agencies, governments, private sector and civil society, and other stakeholders. In particular, there was a push from some low- and middle-income governments, advocates, and civil society representatives for their inclusion in Fund governance, a position supported by the United States. Ultimately, a decision was made to incorporate a broad set of stakeholders into the Fund’s governance structure, as follows:

• A Governing Board (the “Board”) is the principal decision-making body for the Fund, responsible for discussing and approving plans, priorities, principles, budgets, changes to governance and operations, and more. The Board has a total of 21 voting seats (with an equal number of alternates) divided among several constituencies as follows (members as of March 2023 listed here):
  • Nine for “Contributors” (i.e., representatives from donor governments such as the U.S.)
  • Nine for “Co-investors” (i.e., representatives from Fund-eligible country governments)
  • One for philanthropic/foundation contributors
  • Two for representatives from civil society/community groups (one for the “Global North” and one for the “Global South”).
  • There are also non-voting members on the Board, including a representative from the G20, the Chair and Vice-Chair of the Technical Advisory Panel (see below), plus any other representatives from entities as approved by the Board. There are additional Observer seats as well, including representatives from the Trustee, Implementing Agencies, and the Secretariat (more on these below).
• A Technical Advisory Panel (TAP) is the principal advisory body to the Board, comprised of up to 20 experts drawn from a range of PPR-relevant fields and practice areas. The TAP has responsibilities for advising the Board on technical, financial, and other matters, including review, analysis, and recommendations related to proposals for funding. A senior WHO official (currently Mike Ryan) is the TAP Chair, and a “non-WHO” expert (currently Joy St. John from the Caribbean Public Health Agency) is the Vice Chair. Beyond these 20 (membership shown here), additional experts may be called to contribute on an as-needed basis. TAP members serve for two years, up to two consecutive terms.
• The Secretariat is the office responsible for day-to-day FIF operations and performs duties including convening Board and TAP meetings, developing the calls for proposals, compiling progress and evaluation reports, liaising with external partners, and other activities. Located at the World Bank, the Secretariat is comprised of a small staff of “professional and administrative staff employed by the World Bank or seconded to the World Bank from WHO.”
• The Trustee for the pandemic FIF is the World Bank, which is responsible for receiving and holding funds from contributors, providing financial oversight and agreements, reviewing financial reports, and other tasks.

The current Board is comprised of interim members put in place as the Fund was first established. A “Board reset,” which may result in turnover of some individuals currently occupying Board seats, is scheduled for May 2023.

Operations

The Fund’s Operations Manual describes key current operational aspects as follows:

Funding modalities, eligibility, and implementing agencies

The Fund can receive donor funding from governments, intergovernmental organizations, as well as approved non-governmental entities such as foundations/philanthropies. Any donor to the Fund enters an agreement with the Trustee (the World Bank), and contributions from non-governmental entities are subject to review and approval by the Governing Board. Contributions can be made as one-time payments or installments for up to eight years. All contributions are pooled for subsequent allocation by the Governing Board (more on this below). No donor contributions can be earmarked in advance for specific projects or recipients.

Pooled donor funds are to be directed in support of relevant capacity building activities at national, regional, and/or global levels. Countries that are eligible to receive World Bank funding (i.e., the World Bank-defined IBRD and/or IDA countries) are eligible to receive Pandemic Fund support. Regional entities that are specialized technical institutions supporting public health and/or strengthening preparedness capacity and established by governments of one or more eligible countries, as well as regional development communities and economic organizations, are also eligible for funding. Governments and entities that receive funding are known as Beneficiaries.

Funding is not provided directly to Beneficiaries, however. Instead, the Pandemic Fund channels funding through a pre-determined set of “Implementing Agencies” that partner with Beneficiaries to carry out activities that advance the Fund’s mission. The Pandemic Fund cannot provide grants for projects that do not involve an Implementing Agency. Currently, the Fund has named the following 13 Implementing Agencies as eligible:

• Multilateral Development Banks: African Development Bank, Asian Development Bank, Asian Infrastructure Investment Bank, European Investment Bank, Inter-American Development Bank, International Finance Corporation, World Bank
• United Nations Institutions: Food and Agriculture Organization, UNICEF, World Health Organization
• Other Multilateral & Global Health Organizations: Coalition for Epidemic and Preparedness Innovations (CEPI), Gavi the Vaccine Alliance (Gavi), the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

The Governing Board can approve additional Implementing Agencies, subject to a review and accreditation process.

Funding Proposal Review and Approval

Pandemic Fund grants will be allocated via a process of proposal submissions, review, and Board approval. The Secretariat will issue periodic calls for proposals and associated funding envelopes, asking for proposals from eligible parties for investments in specific PPR focus areas. Proposals may be submitted by one or more countries and/or regional entities, and must identify at least one approved Implementing Agency to support project implementation. The Secretariat receives and screens proposals to ensure compliance with the Fund’s governance and operations framework. Among other requirements, each proposal must include a description of its monitoring and evaluation approach, and these results must be tied to a specific results framework that measures progress in raising preparedness scores according to standard evaluation measures such as the WHO’s Joint External Evaluation (JEE) or State Party Self-Assessment Report (SPAR) and the World Organization for Animal Health’s Performance of Veterinary Services (PVS) Pathway tool.

Each proposal that meets compliance standards will be sent to the TAP for review and scoring. The TAP will review submissions for adherence to the criteria in the request for proposals, as well as other aspects such as technical soundness, cost efficiency, fit within the broader context of PPR and health financing, impact, and equity. Each proposal will be scored according to specific criteria and a system developed and approved in advance by the Governing Board.  The TAP will submit its written assessments and scores to the Governing Board via the Secretariat, for final review and approval. The Governing Board then decides on allocations for approved proposals based on their assessed merit and resources available for distribution.

In January 2023, the Pandemic Fund asked potential Beneficiaries to submit preliminary expressions of interest for funding and through February had received a reported 650 such submissions. On March 3, 2023 the Fund released its first official call for proposals, which focuses on one or more of the following technical areas: 1) disease surveillance systems, 2) laboratory systems, and/or 3) strengthening human resources/public health workforce capacity. The Fund is making available $300 million for this round of proposals, with submissions required by May 2023 and final funding decisions expected by July 2023.

U.S. Engagement

The U.S. has publicly and actively supported the effort to direct additional multilateral financing for COVID-19 and PPR efforts more broadly since President Biden took office in January 2021. Soon after his inauguration the President released a National Strategy for the COVID-19 Response and Pandemic Preparedness that emphasized the need for more funding for PPR, and called on the U.S. Treasury to work with the World Bank and others to promote additional financing through multilateral financial institutions. At the U.S.-hosted first Global COVID-19 Summit in September 2021, the White House specifically called for the creation of a pandemic financial intermediary fund to be housed at the World Bank, and committed the first funding toward the mechanism. The U.S. Treasury, as the lead government agency for engagement with multilateral financing institutions, has played an ongoing role in advocating for and advancing the development of the Pandemic Fund, with U.S. Treasury Secretary Janet Yellen frequently voicing support and calling for more donor engagement and financing for this mechanism. The U.S. currently occupies one of nine “Contributor” (donor country) seats on the Pandemic Fund Board.

As the Fund as evolved, the U.S. government has sought to shape its governance and operational aspects according U.S. priorities. Many U.S. priorities for the Fund, as expressed by U.S. officials in response to initial World Bank proposals, have been implemented in the current Fund approach. For example, the U.S. pushed for a more inclusive Board and governance structure that includes recipient country and civil society representation, and sought to expand the set of implementing partners to include existing global health institutions such as Gavi, CEPI, and the Global Fund.

To date, the U.S. has both pledged and paid in more funding to the mechanism than any other single donor. The U.S. made an initial commitment of $250 million for the Fund in September 2021, and in May 2022 announced it was increasing its commitment to $450 million. In May 2023, the U.S. announced it would direct an additional $250 million to the Fund (pending Congressional notification), which brings the total of pledged U.S. contributions to $700 million. This would represent 37% of all donor commitments made so far. As of May 2023, the amount the U.S. has paid in ($450 million) represents about 40% of all financing received by the Fund to date. U.S. contributions have been drawn from a mix of COVID emergency supplemental funding and funding provided to USAID for global health security.”

For its part, Congress has drafted bills in support of more multilateral financing for pandemic preparedness, including through a new fund. The House passed a global health security bill in 2021 that, among other actions, authorized U.S. engagement with and contributions to a new multilateral fund for pandemic preparedness. While that bill was not passed by Congress in 2021, much of the language and expression of support for the Fund was eventually incorporated into the 2023 National Defense Authorization Act, which passed into law in December 2022. That legislation authorizes up to $5 billion in U.S. contributions to the Pandemic Fund over five years ($1 billion per year), and outlines requirements such as that U.S. contributions to the Fund are to not exceed one-third of all donor contributions to the mechanism. White House budget requests in FY 2023 and FY 2024 each asked Congress to provide $500 million for the Fund, but so far Congress has not appropriated any additional funding (beyond already existing COVID-19 emergency funding). Still, in final appropriations bills for FY 2022 and FY 2023, Congress provided the administration with the authority to transfer funding for global health programs more generally to the Pandemic Fund.

Policy Issues

The Pandemic Fund is still quite new, having launched only last year and just now readying its first round of funding. As such, many of the details about its policies, procedures, and operations are still being negotiated and fleshed out, with some changes and clarifications sure to come in the future. Still, enough is known at this point to identify key challenges and issues the Fund faces, now and going forward. These include:

• Limited donor funding to date and uncertain future support. Donors have promised over $1.9 billion to the Fund (including commitments made for future years) and paid in over $1.1 billion so far. However, these funding amounts fall far short of the $10 billion or more each year recommended by the World Bank, WHO, and other groups. It remains unclear whether and how this funding gap can be filled as attention to COVID-19 fades, and as donors and health systems face funding constraints and competing priorities. While there appears to be strong demand for Pandemic Fund grants – the first call for proposals generated submissions from more than 100 countries requesting funding totaling over $7 billion – the longer-term sustainability of the Fund remains in question without more financing, and its reliance on the generosity of donors in the coming years places it in a potentially precarious financial situation.
• Approach and ability to catalyze co-financing is unclear. As the Pandemic Fund’s Governance Framework makes clear, a key objective for the mechanism is to use its resources to leverage additional investments for pandemic preparedness and response from philanthropies and the private sector, as well as by country governments. However, only a limited amount of funding has been committed by philanthropies to date, including from the Gates Foundation ($15 million), Wellcome Trust (about $12 million), and Rockefeller Foundation ($15 million), which together comprise around 2 percent of all commitments to the Fund. In addition, it is still unclear how the Fund will “crowd in” additional PPR financing from domestic governments, particularly given the challenging fiscal environments faced by many low and middle income countries. A Board working group recommended against strict co-financing requirements linked to grants but did recommend co-financing be pursued when possible. The first call for proposals includes a set of principles for co-investments, making clear that mobilizing additional government spending is encouraged but not an absolute requirement. While rules and regulations may evolve for future funding rounds, it will be important to observe if and how much co-financing is mobilized in the first round of funding without specific requirements for it, and how successful the Fund can be in crowding in additional funds from other sources.
• Differing views on priorities by geography, activity, income level, and other aspects of project funding. The Fund has to choose how to spend a limited amount of funding across a broad set of potential projects, which could encompass preparedness and response, animal and human health, local and global capacities, early-stage research and last-mile delivery, and more. For its initial round, the Fund has focused on certain country and regional-level technical areas such as laboratory systems and public health workforce, but that leaves out other areas in need of investment. Going forward, decisions to focus in some areas but not others are likely to be contentious. For example, what the right split between funding country-level, regional-level, and global capacities is. Some advocates have argued for setting a specific target such as 70/20/10 across these three levels, respectively, but no hard and fast rule yet applies. In addition, the Board will have to choose how to balance financing across a range of country income levels, and disparate needs.
• Questions about governance processes and ensuring representative decision-making. At less than a year old, many of the Fund’s governance procedures and norms are still being negotiated and developed, but already there are questions about how it will navigate decision-making processes and ensuring equity and representation, such as:
  • While some steps have been taken toward inclusive governance such as having civil society and recipient country representation on the Board, as sought by the U.S. and global health advocates, it’s not yet clear the extent to which decision-making will be influenced by these stakeholders as opposed to donor governments. There are the same number of Board seats (nine each) for “Co-investor” and “Contributor” countries plus two seats for civil society, but power imbalances can still exist in such situations in practice. Further, the two civil society representatives (one from the Global North and one from the Global South) have been tasked with representing large, diverse international constituencies, and keeping informed of and adequately representing the full array of issues and concerns of their constituencies is a major challenge.
  • Concerns about potential conflicts of interest have also been raised, such as that “Co-investor” countries have a level of influence over funding decisions and also stand to benefit from funding decisions. The Board has been developing a set of guidelines to manage this and other potential conflicts of interest, but it remains to be seen how the Fund rolls out and implements the guidelines, and how robust they turn out to be. As it stands, the Fund’s Operations Manual states all individuals associated with decision-making and/or implementation “must disclose to the Secretariat any actual or potential conflicts of interest…and recuse themselves from decision-making or deliberations in relations to matters where conflicts arise.” Other global health financing mechanisms (including Gavi and Global Fund) have had to navigate this issue to some extent but it will be particularly important for the Fund as it establishes itself, builds trust and seeks legitimacy for its work.
  • Ensuring transparency of decision-making and operations for the Fund will be important. Some notable steps toward greater transparency have already been taken, including having the Secretariat organize (occasional) open meetings with external stakeholders such as civil society representatives to provide information and accept input, posting Board meeting minutes detailing decisions and other important information, and creating a website with updated donor funding information, news, and other resources. As the review process for grants begins and funding begins to be awarded, transparency about how decisions are made, along with amounts, recipients, and projects funded, are likely to help maintain trust among interested parties. To this end, the Board released the instrument and scoring approach that will be used by the TAP to rank and score proposals in the first round of funding. It is expected that results from the reviews will be made public to an extent, along with posting and sharing of the Fund’s overall results and outcomes.
• Level of integration and coordination with existing global health and PPR efforts remains to be seen. The Fund was designed to be additive and build upon ongoing PPR and global health efforts. Among its key principles are that it “complements the work of existing institutions” and that it will “serve as an integrator rather than become a new silo that only furthers fragmentation.” One way it seeks to do this is by requiring its funding be channeled through existing institutions (i.e., “Implementing Agencies”) rather than building a new vertical funding structure. The Fund also requires that proposals address how their projects would integrate with and build upon existing plans and PPR frameworks Joint External Evaluations (JEEs), the International Health Regulations (IHR), and country-level National Action Plans for Health Security (NAPHS) or other plans, and proposals must outline how different key actors will coordinate their efforts. Still, as the Fund moves from concept to implementation it will be worth monitoring how effective these principles are and how closely it adheres to this vision. Depending on the focus and scope of projects, countries could have to integrate across many disparate and fragmented actors, including other multilateral efforts, bilateral programs, and overlapping (but potentially separately funded) primary health care, universal health coverage or health system strengthening efforts. Already, this challenge has emerged. The Global Fund, one of the Pandemic Fund’s 13 approved implementing entities, submitted an expression of interest to the Fund, but has since decided not to formally apply for funding in round one, while it continues to assess coordination and synergies between the two organizations.
• Demonstrating impact in the next few years will be important but challenging. As a new entity, the Fund does not yet have a track record it can point to and likely faces a relatively short time window to demonstrate its effectiveness to donors, partners, and communities. Setting ambitious but attainable goals and objectives will be important, especially ones that can be measured, quantified and progress tracked against. To this end, the Fund’s Results Framework outlines monitoring and evaluation requirements for funding recipients, with each implementing agency required to report annually to the Secretariat on progress according to standard metrics like the JEE and SPAR. The Secretariat will then provide an annual, overall results report for the Board. The challenges may come with definitively demonstrating impact, especially if metrics are hard to interpret and/or could take time (perhaps years) to improve. There will be a balance between making quick progress to show donors that funds are having an impact, and allowing enough time for chosen projects to be implemented. In addition, given that the ultimate goal is to help countries prevent epidemics and pandemics, it will be difficult to measure such an effect beyond these intermediary metrics.
• Future U.S. funding for the Pandemic Fund, as well as coordination of this support within the context of existing global health programs, remains to be determined. The future of U.S. funding for the Fund is unknown, as the Biden Administration has so far been able to primarily tap pre-existing funds from COVID-19 emergency appropriations, along with global health security funds. Additional amounts, specifically appropriated by Congress for the Fund, are not a given. In the current period of divided government and budget constraints, in advance of a Presidential election year, it is not clear there is a bipartisan consensus on more U.S. support for the Fund – let alone the $1 billion annually that the White House supports and Congress has authorized for this purpose. Also, given the already long-standing U.S. support for bilateral and multilateral global health efforts such as PEPFAR and the Global Fund, as well as a number of dedicated bilateral global health security programs, it remains to be seen how the U.S. will balance its support for the Pandemic Fund with that for its other programs. Any further U.S. contributions to the new mechanism might come in addition to discretionary funding amounts Congress provides for other U.S. global health programs, potentially leading to tension about the right balance. Further, in places where U.S.-funded global health programs and Pandemic Fund supported projects occur together geographically, U.S. programs might have to consider how best to coordinate and, where appropriate, integrate efforts.

Nine months ahead of the first presidential primary of the 2024 election season, many voters, especially women, say candidates’ views on abortion will again be a key issue, and Democrats hold a strong edge over Republicans on the issue, a new KFF Health Tracking Poll finds.Three in 10 registered voters (30%) – and a third of women voters (35%) – say they will only vote for a candidate who shares their views on abortion. This finding includes nearly half (46%) of Democrats, almost a quarter (23%) of independents, and one in five (20%) Republicans. Similar shares of voters who say abortion should be legal in all or most cases (31%) and those who say it should be illegal in all or most cases (28%) will only vote for a candidate who shares their views.When asked which party best represents their views of abortion, more people say the Democratic Party (42%) than the Republican Party (26%), while about a third (32%) say neither party does.While most partisans say their party best represents their abortion views, Republicans are more than twice as likely as Democrats to say that neither party represents their views (21% v. 9%) or that the other party does (6% v. 1%).The Democratic Party also has an edge over the Republican Party on the abortion issue among independent voters (36% v. 13%) and among women voters under age 50 (45% v. 24%).

Most Don’t Trust the Supreme Court to Make Decisions in Reproductive Health Cases

Nearly a year after the Supreme Court’s decision ending the constitutional right to an abortion, the poll finds most (58%) of the public disapproves of its job performance generally, and most don’t trust the Court’s ability to decide cases related to reproductive and sexual health. Almost four in 10 (37%) say they trust the court “a lot” or “somewhat” to make the right decision on reproductive and sexual health, fewer than say the same about other topics such as science and technology (55%), the role of the federal government (53%), and the Affordable Care Act (49%).Among women under 50 – the group most directly affected by the Court’s decision overturning Roe v. Wade – about seven in 10 (72%) say that they trust the court “not too much” or “not at all” to make decisions about reproductive and sexual health. This finding includes most (56%) Republican women under 50, as well as larger majorities of Democratic (81%) and independent (75%) women in that age group.The poll also gauges the public’s knowledge and views about mifepristone, one of the drugs used for medication abortion that is at the center of an ongoing court battle that could affect future availability. The Supreme Court last month blocked a lower court’s order that would have stopped the drug’s distribution and availability nationally. As the case proceeds, the Food and Drug Administration’s current rules remain in effect, and mifepristone remains available for abortion where abortion is legal.

Nearly two-thirds (65%) of the public say they have at least some confidence in the FDA’s efforts to ensure that medications are safe and effective. Six in 10 (60%) also say it would be inappropriate for a court to overturn the FDA’s approval of a medication, including most Democrats (73%) and independents (57%). Republicans are divided, with half (50%) saying it would be appropriate and half (49%) saying it would be inappropriate. 

In States that Have Banned or Limited Abortion, Many Are Confused About Whether It Is Legal There

Awareness of mifepristone has doubled this year, with nearly two-thirds (64%) of the public saying they’ve heard of the drug now compared to 31% in January. At the same time, there remains widespread confusion and uncertainty about whether the use of mifepristone for abortion is legal in states that have banned or severely limited the procedure.In the 14 states with bans on all abortions, a third (33%) of residents know medication abortion is illegal there. About one in eight residents (13%) incorrectly believe medication abortion is legal there and more than half are unsure of the legality of abortion in their state. In 11 other states where abortion is legal but restricted, a quarter (25%) of residents know that medication abortion remains legal there, while 15% mistakenly believe it is illegal and six in 10 are unsure. There are similar levels of confusion among women under 50.The poll finds that two-thirds (66%) of the public – including almost half of Republicans (47%) – say they are concerned that abortion bans make it hard for doctors to treat major complications during pregnancies. The survey also finds that some women are changing their approach to contraception to reduce their likelihood of getting pregnant due to concerns about being unable to access an abortion.Specifically, more than half (55%) of women under age 50 say that they or someone they know has taken at least one of six precautions, including using long-acting birth control like an IUD or an implant (32%), buying emergency contraception (28%), getting a new prescription for oral contraception (28%), delaying getting pregnant (22%), getting a vasectomy or tubal ligation (20%), or stocking up on oral contraceptives (17%).METHODOLOGYDesigned and analyzed by public opinion researchers at KFF, the survey was conducted from May 9-19, 2023, online and by telephone among a nationally representative sample of 1,674 U.S. adults, including 799 women ages 18 to 49. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample and 4 percentage points for women 18-49. For results based on other subgroups, the margin of sampling error may be higher.

As the U.S. tries to address rising rates of mental health issues, the impact of the new 988 national crisis hotline and other innovations will be limited if states don’t have the underlying crisis services available when people are directed to them.

The core crisis services include crisis hotlines that connect individuals to trained counselors, mobile crisis units that provide in-person crisis support services, and crisis stabilization units that provide short-term observation and crisis stabilization in a non-hospital environment. 

A new KFF survey finds that state Medicaid programs, as the single largest payer of behavioral health services in the country, are taking steps to help implement and fund crisis services, though gaps remain. The Medicaid population may be particularly affected by the availability and quality of such services, as 39 percent of enrollees have mild, moderate, or severe mental health or substance use disorder conditions.

State Medicaid programs also have access to new federal dollars to support, staff and expand crisis services, through the American Rescue Plan Act’s (ARPA) mobile crisis intervention services option that started April 2022, and the option is available for five years.

Among the key findings of KFF’s Behavioral Health Survey of state Medicaid programs: 

•    About three-quarters of responding states (33 of 45) do not cover all three core crisis services for adults under fee-for-service Medicaid, but most states cover at least one core crisis service (41 of 45).

•    Over half of responding states (28 of 44) report that they have taken up or plan to implement the American Rescue Plan Act (ARPA) mobile crisis intervention services option.

•    Almost all responding states (38 of 44) reported experiencing or expecting at least one obstacle to implementing crisis services, particularly workforce shortages and geography-based challenges.

A second KFF analysis uses the survey findings to explore state Medicaid programs’ delivery, administration, and integration of behavioral health care. Medicaid covers a disproportionate share of adults with mental illness and/or substance use disorder (22% vs. 18% of all non-elderly adults).

As states continue to expand behavioral health services coverage to close access gaps and address the COVID-19 pandemic’s impact on mental health and substance use disorders, they may face continued upward budget pressures in behavioral health services spending due to increased utilization. States and analysts may further study the complex Medicaid behavioral health delivery system, examining access and outcomes associated with various delivery and financing mechanisms.

Moreover, numerous existing and proposed federal initiatives aim to employ strategic policies to enhance the accessibility, quality, and availability of behavioral health care. For example, the Consolidated Appropriations Act (CAA) passed workforce requirements that aim to increase the accessibility and availability of behavioral health care, including requirements for Medicaid provider network directories and funding for new psychiatry residency positions. 

These two new analyses are the last in a series of six KFF issue briefs that report data from the Behavioral Health Supplement to our 2022 state Medicaid budget survey.

A new KFF analysis finds about 1 in 20 privately insured people (5.7%) received at least one ACA preventive service or drug that could be affected by a now-stayed U.S. District Court ruling in Braidwood Management v. Becerra, which found the Affordable Care Act’s (ACA) preventive services mandate partially unconstitutional. The district court also found that pre-exposure prophylaxis (PrEP), medication recommended for HIV prevention, violates the religious rights of those who have objections to its use.

On Monday, May 15, the 5th Circuit Court of Appeals issued an administrative stay on the district court’s Braidwood ruling while they consider an appeal in the case. Major private health insurers have announced that they do not plan to make changes – if any were to be made at all – until after a final decision has been made.

The analysis uses 2019 claims data to examine the number of people who received preventive services that could be affected by the District Court’s ruling. It estimates that 10 million people received services that would no longer have to be covered without any cost sharing if the ruling is allowed to stand. Statins, which are used to treat people at risk of cardiovascular disease, are the most commonly used preventive service potentially affected.

The Texas District Court ruling applies only to preventive services recommended by the US Preventive Services Task Force (USPSTF) after 2010, when the ACA was enacted. As a result, the ruling could affect more services and people over time – as new drugs and treatments are developed, recommended, and adopted. For example, this analysis – which relies on 2019 claims data to reflect utilization in a typical pre-pandemic year – does not consider the ruling’s impact on more recent preventive service recommendations, like PrEP for HIV.

Among treatments approved in and before 2010, the ruling would not affect the costs of other common preventive services, such as vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), women’s preventive health services (e.g. contraception and prenatal care), or mammography and cervical cancer screenings.

The federal government can continue enforcing the USPSTF’s entire preventive services requirement while the 5th Circuit considers the Department of Justice’s motion for a stay pending appeal.