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.

Recent efforts to develop and improve behavioral health crisis response systems have been marked by several key federal initiatives. These include national guidelines for crisis care put forth by SAMHSA in 2020, an initiative for states to use Medicaid funding for mobile crisis services through the American Rescue Plan Act (ARPA) in 2021, and the 988 crisis line rollout in 2022. Most recently, the Consolidated Appropriations Act–passed in December 2022– included several provisions aimed at enhancing and evaluating the behavioral health crisis continuum. This surge in action has grown in light of longstanding and worsening behavioral health issues, tragic incidents involving law enforcement, and growing reports of psychiatric boarding in emergency departments (EDs).

Medicaid – the single largest payer of behavioral health services in the country – is particularly well positioned to partner with state behavioral health authorities and other stakeholders to plan, implement, and monitor the behavioral health crisis response systems.  Further, the Medicaid population may be particularly impacted by these changes, as 39% have mild, moderate, or severe mental health or substance use disorder conditions.

To better understand the development, implementation, and coverage of crisis services in state Medicaid programs, KFF conducted a Behavioral Health Survey of state Medicaid programs as a supplement to its 22nd annual budget survey of Medicaid officials conducted by KFF and Health Management Associates (HMA). We surveyed state Medicaid officials about the services that were in place in state fiscal year (FY) 2022 or implemented/planned for FY 2023, as well as challenges they face. Forty-four states (including the District of Columbia) responded to the survey, although response rates varied by question. This issue brief utilizes this survey data to answer three key questions:

• What are the core behavioral health crisis services and how often are they covered by states?
• Are states pursuing opportunities for enhanced federal funding for crisis services?
• What challenges are confronting Medicaid programs in the implementation and delivery of crisis services?

Background

Crisis behavioral health services provide access to trained mental health professionals for individuals experiencing mental health or substance use emergencies–an alternative to emergency departments and law enforcement. Literature has shown that crisis services divert people away from psychiatric hospitalization and reduce the need for intervention within emergency departments or by law enforcement. It is estimated that law enforcement officers spend a sizable amount of their time responding to behavioral health calls, while ED visits for behavioral health reasons continue to rise; however, professionals in these settings are generally not equipped to treat mental health conditions or safely de-escalate crises. Without access to necessary evidence-based care, mental health crises can worsen or prolong.

National guidelines identify three core crisis services that should be accessible to anyone who is experiencing a behavioral health crisis: crisis hotlines, mobile crisis units, and crisis stabilization. While crisis residential and crisis respite services are a part of the crisis continuum and may also provide interventions to help to stabilize crisis, they are not considered core services. Although these crisis services do not necessarily have to be accessed in a specific order, Crisis Now illustrates how they may be accessed and used.  Core crisis services are described below in Table 1:

SAMHSA’s national guidelines report that integration of services across systems will reduce fragmentation and improve care transitions. Examples of technology and integration that may help include a system for assessing crisis levels, a crisis bed registry, GPS mobile crisis dispatch, and the ability for crisis staff to schedule appointments. Further, data dashboards may provide ongoing insights into service utilization and impact of crisis services.

Medicaid Coverage of Core Crisis Services

About three-quarters of responding states (33 of 45) do not cover all three core crisis services for FFS adults, but most states cover at least one core crisis service (41 of 45) (Figure 1). Medicaid programs are less likely to cover crisis services compared to other behavioral health service categories. Despite this generally lower coverage, the landscape of crisis response systems is evolving across states, driven in part by the opportunity for enhanced federal matching funds for qualified mobile crisis services (see next section of this brief). For example, Massachusetts is implementing a multi-year roadmap for behavioral health reform that includes a 24/7 help line, clinical assessment, and referral to treatment. The state of Montana is working toward aligning its crisis services with the Crisis Now Model. Crisis hotline services are available to anyone free of charge across all states, but some Medicaid programs help to finance crisis hotlines by reimbursing crisis hotline services, which might include 988 or other hotlines.

States report higher coverage rates for mobile crisis and crisis stabilization units but lower coverage for crisis hotlines under adult fee-for-service (FFS) Medicaid. However, it is unclear how widespread these services are within states and whether they align with best practice recommendations, such as trauma-informed care. (These findings do not account for variations in coverage provided by managed care organizations (MCOs) or Section 1115 waivers.)

• Nearly three-quarters of responding states (33 of 45) reported mobile crisis coverage for adults in FFS programs. People experiencing a crisis may receive help from mobile crisis teams, which are usually dispatched from crisis hotlines, providers, emergency medical services, or law enforcement.
• Nearly two-thirds of responding states (28 of 45) report adult FFS coverage of crisis stabilization units. Research suggests that care provided in crisis stabilization facilities may produce cost savings compared to emergency department or inpatient care.
• Crisis hotlines are the least frequently covered core crisis service (22 of 45 responding states). Crisis hotline services are available to anyone free of charge across all states, but some Medicaid programs help to finance crisis hotlines by reimbursing crisis hotline services, which might include 988 or other hotlines. One reason why coverage for this crisis service is lower than others may be the difficulty in obtaining insurance information during emergency crisis calls. Some states are finding ways to address this issue, with the National Association of State Mental Health Program Directors (NASMHPD) reporting that some states are surveying callers about Medicaid coverage and utilizing an administrative federal match based on share of Medicaid-covered callers.

Most of the states that cover mobile crisis also report that they currently require or are planning to require peer supports on their teams. Peer supports are individuals with lived experience, and research and national guidelines support their involvement in mobile crisis teams. A total of 7 states required peer supports on mobile crisis teams as of FY2022, with 13 more states planning to require it in FY2023. Several states report that they encourage peer support, but do not make it mandatory. Other states have plans to include peer supports in subsequent years or on a subset of teams. Arizona, for example, plans to require peer support specialists on 25% of mobile teams in FY 2023.

Options for Enhanced Federal Funding for Crisis Services

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 (Figure 3). The option under ARPA is available to states for 5 years, beginning April 1, 2022. Medicaid programs that provide qualifying community-based mobile crisis services under this option will receive 85% enhanced federal matching funds for the first three years of implementation. This enhanced funding must supplement, not supplant, the previous level of state funding for qualifying mobile crisis services. While it is not necessary for mobile crisis services to be available across the state or to all populations to qualify for enhanced match, states must meet certain criteria, such as 24/7 service among participating providers. Among states that chose to pursue the ARPA option, 8 states reported implementation of qualifying mobile crisis services in FY 2022; 11 states reported plans to implement in FY 2023; and 9 in FY 2024 (Figure 3). Among states without plans to implement ARPA mobile crisis services or with an undetermined status, reasons for not pursuing this option included pre-existing non-ARPA crisis services and/or difficulty understanding and meeting the ARPA requirements for the enhanced match. Through funding provided by the ARPA, planning grants were awarded to 20 state Medicaid programs–to help them prepare for the implementation of qualifying mobile crisis services.

Less than one-quarter of states (8 of 43) are using or plan to access enhanced administrative match to support the technology needed to support implementation of crisis call centers or other crisis services. SAMHSA’s best practice guidelines advocate for an “air traffic control” model for crisis services that includes a system for assessing crisis levels, wait times, and linkage to additional services, as well as the ability for crisis staff to schedule appointments, a crisis bed registry, GPS mobile crisis dispatch, and performance monitoring dashboards. ARPA guidance explains that states can apply a 90% enhanced administrative match for the development of certain technology systems to help implement crisis services (and receive an ongoing 75% match for operations of these systems). Kentucky and Massachusetts are applying these funds toward crisis hotline integration or development, while New Jersey focuses on mobile response teams and vacancy tracking.

Challenges Confronting Medicaid Programs in the Implementation and Delivery of Crisis Services

State Medicaid programs often collaborate with multiple state agencies to design and implement crisis services. To gain a deeper understanding of the barriers associated with the implementation and delivery of these services, we asked state Medicaid programs about the challenges states have faced or anticipate facing. Additionally, we asked them to identify which of these areas posed the most significant obstacles.

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 (Figure 4). Workforce shortages and geographic challenges are not unique to crisis services, as other areas of behavioral health report similar barriers. Other challenges include provider training needs and scope-of-practice limitations. When we asked states to identify their biggest challenge, they overwhelmingly pointed to the shortage of a qualified workforce as their most significant obstacle.

• Workforce Shortages. Finding qualified mental health professionals willing to work in crisis services and provide around-the-clock care, especially overnight, is a significant challenge. This high-stress environment contributes to high turnover rates, complicating the fulfillment of some ARPA requirements, such as maintaining a 24/7 two-person team. To address these workforce shortages, several states, including Nevada, have implemented strategies like allocating start-up funds to help providers expand their crisis workforce.
• Geographic Challenges. Increased travel times in rural areas can result in longer response times for individuals in need. Some states have considered telehealth as a solution, although limitations exist for those without smartphones, reliable services, or comfort using them. Predicting demand in rural areas is challenging due to less concentrated populations, complicating 24/7 multidisciplinary team staffing. Staff safety is also a concern in areas with poor cell phone or internet reception. Additionally, states with significant tribal populations face added challenges in planning and coordinating efforts across agencies, MCOs, and providers.
• Provider training needs. New and existing crisis professionals typically need initial and ongoing training in crisis services and population-specific topics. States emphasize the importance of providing trauma-informed, developmentally, and culturally appropriate care, which may necessitate additional trainings. States recognize the importance of these trainings, but point out that because of workforce shortages, it is difficult to take the existing crisis workforce out of the field for trainings. States are also challenged by a shortage of available trainings. To address the scarcity of available trainings in its state, Massachusetts is funding a behavioral health training clearinghouse containing free trainings.
• Scope-of-practice limitations. Some states report that the roles and responsibilities of non-licensed staff, such as certified peers, are not always defined by state licensing boards. The shortage of staff and the limited roles they can perform also affect crisis services delivery. For example, in one state, a significant proportion of the workforce is comprised of unlicensed qualified mental health professionals who cannot diagnose or provide assessments for crisis services.

In addition to the challenges specified above, several states provided information about additional challenges:

• Funding. Some states are concerned about sustainability of financing for crisis services, particularly as the ARPA enhanced funding (85% federal match) for community-based mobile crisis services is effective only for the first three years of implementation. For example, Oregon recommends permanent implementation of the enhanced federal match for qualifying crisis services. At present, crisis service financing relies heavily on local and state funding and block grants—though some states have added telecommunication Medicaid is the primary and one of the only insurers reimbursing for these services—even though people with other types of coverage are also served by behavioral health crisis systems. For example, Vermont points out that crisis services should be available to all regardless of insurance and identified the lack of mobile crisis coverage from Medicare and commercial payers as a challenge.
• “Connecting” crisis care and other challenges. States also reported concerns around developing interconnections between 988 and the state’s existing infrastructure for effective “dispatching”, as well as improving cultural awareness and sensitivity to communities.

Looking Ahead

Keeping pace with larger federal and state initiatives, many Medicaid programs are developing or strengthening behavioral health crisis services. 988’s launch and enhanced federal funding opportunities have sparked developments, but states are unsure what will happen when enhanced funding opportunities expire. In addition, workforce shortages, questions about linking and coordinating across systems, and other logistical issues continue to pose challenges both within Medicaid and crisis systems generally.

Recent federal initiatives aim to mitigate some of these challenges. The Consolidated Appropriations Act, passed in December 2022, includes several provisions aimed at enhancing and evaluating the behavioral health crisis continuum. The Act establishes the Behavioral Health Crisis Coordinating Office within SAMHSA, directing it to identify and publish best practices. Additionally, the Act tasks various agencies with producing reports that evaluate the performance measures and outcomes of the behavioral health crisis continuum. Federal investments in the development and implementation of the 988 number have helped Lifeline improve answer rates, even with increases in outreach volume.

Despite recent advances in crisis services, uncertainties persist, including questions of how to integrate services across the crisis continuum and how to secure long-term sustainable funding. According to SAMHSA, crisis systems will be most effective when they can coordinate with each other and connect with other health care areas. The financing of crisis response systems is still emerging, with Medicaid currently a main insurer reimbursing for crisis services. However, Medicaid’s coverage is, at present, less comprehensive for crisis services compared to other categories of behavioral health benefits, though states may continue to enhance this coverage in coming years. As crisis response systems continue to grow and expand, states are navigating a variety of concerns—including workforce shortages, training needs, geographic challenges, and uncertainty about sustainable funding.

If you or someone you know is considering suicide, contact the 988 Suicide & Crisis Lifeline at 988

This analysis uses private insurance claims data to examine the number of people who received preventive services 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 Affordable Care Act (ACA) requires most private health plans to cover some in-network preventive services without cost-sharing for enrollees. On March 30, 2023, the U.S. District Court in the Northern District of Texas excluded from the requirement all preventive care recommendations issued by the United States Preventive Services Task Force (USPSTF) on or after March 23, 2010, when the ACA was signed into law. The district court also found that preexposure prophylaxis (PrEP), medication recommended for HIV prevention, violates the religious rights of those who have objections to its use.

The analysis finds that about one in 20 privately insured people – about 10 million people in total – received at least one ACA preventive service or drug in 2019 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 analysis is available through the Peterson-KFF Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

Background

The health care coverage and financing landscape for people with and at risk for HIV in the U.S. is highly fragmented and made up of a patchwork of payers and programs. Each has its own eligibility requirements, services and benefits, cost sharing obligations, and financing structure. Further, program eligibility and benefits vary by state and in some cases, even more locally, leading to uneven access across the country and some people are left out of the system entirely. The Affordable Care Act (ACA), passed in 2010, expanded access to coverage and services for millions of people, including people with and at risk of HIV and as a result, the number of uninsured people has fallen significantly. Most people with HIV do have insurance coverage, particularly through Medicaid and private insurance, and many receive support from the Ryan White HIV/AIDS Program, the nation’s safety net program for people with HIV. This table provides an overview of the major payers and programs that provide coverage and services to people with and at risk of HIV. It builds on and updates earlier work published in the Lancet.

Download the full version of this table (.pdf)