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)

A new KFF brief examines the return of grantees and clinic sites to the Title X network under the Biden Administration, which reversed Trump Administration regulations that prohibited Title X sites from providing abortion referrals and having co-located abortion services. For more than 50 years, the federal Title X program has provided family planning services to nearly four million people a year through a network of clinics. The program is part of the U.S. public health safety net designed to serve people with lower incomes and those without insurance who otherwise cannot afford family planning services.

As a result of the Trump Administration rules, nearly 1,280 sites withdrew from the Title X program. Of the 411 Planned Parenthood sites that left the program under the Trump Administration, 286 (70%) have rejoined. Of the 869 other sites that left the program, 531 (61%) have returned. 

At the same time, 777 new sites that were previously not part of the program have joined, bringing the current Title X network back to 4,108 sites, which is 2% more than the original 4,010 sites before the Trump Administration regulations. All six states (HI, ME, OR, UT, VT, WA) that left the Title X network under the Trump Administration have returned with most of their sites, or they expanded their networks to new ones.Ongoing litigation challenging the Biden Administration Title X regulations continues, and its outcome could result in withdrawals and disqualifications. Current Title X regulations require clinics to provide pregnancy options counseling that includes abortion as an option. In states where abortion is now banned, there are examples of policies that require Title X clinics to exclude counseling on abortion, which is in direct conflict with Title X regulations. These policies may disqualify grantees in these states from participating in the program. 

Read “Rebuilding the Title X Network Under the Biden Administration” to learn more about the Title X program and network.

Asian, Native Hawaiian, and Other Pacific Islander (NHOPI) people are a diverse and growing population in the U.S. (Figure 1). Asian people are the fastest-growing racial or ethnic group in the United States, almost doubling from 10.5 million to almost 20 million between 2000 and 2020. In addition, there are nearly 700,000 people in the country who identify as NHOPI. In this data note, we use 2021 American Community Survey (ACS) data to examine how demographic characteristics as well as measures of health coverage and other social and economic factors that drive health and health care vary for Asian and NHOPI people overall and by subgroups. We include data for smaller subgroups wherever available. Instances in which the unweighted sample size for a subgroup is less than 50 – which are smaller than what we would typically include in analysis like this — are noted in the figures, and confidence intervals for those measures are included in the Appendix. Although these small sample sizes may impact the reliability, validity, and reproducibility of data, they are important to include because they point to potential underlying disparities that are hidden without disaggregated data, further exacerbating health inequities.

Examining experiences among Asian and NHOPI people is important since broad data for Asian people often mask underlying disparities among subgroups of the population and disaggregated data are often not available or reported for NHOPI people. Understanding the experiences of Asian and NHOPI people is particularly important at this time given growing concerns about mental health and well-being amid a significant uptick in anti-Asian hate incidents since the pandemic, an increased focus on advancing health equity and addressing racism, and ongoing efforts to improve data collection and reporting, particularly for smaller population groups and subgroups of the broader racial and ethnic categories.

Demographics

The majority of Asian and NHOPI people in the U.S. are citizens, adults, and many are parents or living in multigenerational households (Figure 2). Asian and NHOPI people included larger shares of noncitizens relative to White people (25% and 14% vs. 1%). One in five Asian (20%) and 19% White people were children, while more than one in four (26%) NHOPI people were children. Larger shares of Asian people lived in households comprised of parents with children or multigenerational households as compared to White people (42% vs. 33%).

Citizenship and household status varied among Asian and NHOPI subgroups: For example, the share of Asian people who are noncitizens ranged from 5% among Hmong people to 55% among Mongolian people. Among NHOPI people, Native Hawaiian and Chamorro people were significantly less likely than NHOPI people overall to be noncitizens (at less than 1%). In contrast, Marshallese people were more likely to be noncitizens (54%). This variation reflects differences in birth citizenship rights across locations to which NHOPI people trace their origins. Specifically, people born in Hawaii and Guam (Chamorro people) are U.S. citizens by birth, while other Pacific Islander people, including those born in in the Marshall Islands, which is part of the Compact of Free Association (COFA) with the U.S are not conferred U.S. citizenship at birth. The share of these groups who are children also ranged widely, from 9% of Japanese people to 36% of Hmong people among Asian subgroups and from 17% of Fijian people to 43% of Marshallese people among NHOPI subgroups. Household composition also varied by subgroup. Among Asian subgroups, the share who were parents or living in multigenerational households ranged from 27% for Japanese people to 68% for Bhutanese people. Among NHOPI subgroups, Native Hawaiian people (27%) were less likely than the group overall to be in a multigenerational household, while Marshallese people were more likely (48%).

Health Coverage

As of 2021, among the nonelderly population, 6% of Asian people and 11% of NHOPI people were uninsured (Figure 3). The uninsured rate for Asian people was slightly lower than the rate for White people (7%), while the rate for NHOPI people was higher. Across both groups, uninsured rates were lower for children compared to nonelderly adults. The shares of Asian people covered by private coverage were higher than the shares for White people and the shares covered by Medicaid were lower. In contrast, NHOPI people were less likely to have private coverage and more likely to be covered by Medicaid, with over half (52%) of NHOPI children being covered by Medicaid or the Children’s Health Insurance Program (CHIP).

There are wide variations in uninsured rates among Asian and NHOPI subgroups (Figure 4). As of 2021, among nonelderly Asian people, uninsured rates ranged from 4% for Asian Indian and Taiwanese people to 28% for Mongolian people. Among NHOPI people, uninsured rates ranged from 5% for Chamorro people to 24% for Marshallese people, although uninsured rates for other NHOPI subgroups were not statistically significantly different from nonelderly NHOPI people overall. Uninsured rates further varied by citizenship status, with higher uninsured rates for noncitizens across most groups. Among nonelderly Asian noncitizens, uninsured rates varied from 5% for Japanese people to 38% for Mongolian people. There were no statistically significant differences in uninsured rates among nonelderly NHOPI noncitizens. Of note, the sample sizes for some noncitizen subgroups were small (<50), which can lead to a higher degree of uncertainty, i.e., larger confidence intervals for their measures. Confidence intervals for each subgroup measure in Figure 4 can be found in the Appendix.

Socioeconomic Differences

A variety of social and economic factors influence individuals’ access to health coverage, their ability to access health care, and their overall well-being. While as a broad group Asian people often fare similar to or better than White people across many of these measures, some subgroups fare worse. On the other hand, NHOPI people generally fare worse than their White counterparts across a range of social and economic measures.

Data show variations in socioeconomic measures among nonelderly Asian and NHOPI subgroups, which may contribute to the differences in health coverage (Figure 5). Among Asian subgroups, there was an almost five-fold difference in the share of people who have received a bachelor’s degree or higher, with 18% of Laotian people having a bachelor’s degree or higher as compared to 87% of Taiwanese people. Overall educational attainment is lower among NHOPI people, with a lower share of Marshallese people (6%) having a bachelor’s degree or higher compared to nonelderly NHOPI overall, and a higher of Chamorro people (28%) having at least a college degree. The share of Asian households with at least one full-time worker also varied by subgroup, ranging from 66% among nonelderly Mongolian people to 91% among nonelderly Asian Indian people. Among NHOPI people, Fijian and Samoan people were slightly more likely than the overall group to have at least one full-time worker. Similarly, household income among Asian subgroups varied widely with the share of nonelderly people who lived in a low-income household (below 200% of the federal poverty level or $43,920 for a family of 3 in 2021) ranging from 12% among Asian Indian people to 55% among Mongolian people and 52% among Burmese people. Some of these differences are likely driven by differences in citizenship and visa status. For example, those entering the U.S. with work visas likely have higher median household incomes compared to those that entered as asylees and/or refugees. Many Burmese people immigrate to the U.S. as refugees fleeing war in their home country, which could contribute towards their lower household incomes. On the other hand, higher earning groups such as Taiwanese people and Asian Indian people usually immigrate through work visas. Despite eight in ten nonelderly Marshallese people living in a household with at least one full-time worker, 63% lived in a low-income household, while only 27% of Chamorro and Fijian people were low-income. Lower educational attainment as well as higher shares of noncitizens may in part explain the higher shares of Marshallese people living in low-income households.

Key Issues Looking Ahead

Understanding the experiences of Asian and NHOPI people is of particular importance at this time given growing concerns about mental health and well-being amid a significant uptick in anti-Asian hate incidents. The COVID-19 pandemic and underlying racism and discrimination have contributed to a significant rise in hate crimes against Asian people in the United States, which have contributed to deteriorating mental health among Asian people. In a 2021 survey, a majority of Asian Americans cited COVID cases being first reported in China and President Trump as major reasons for discrimination against the Asian and Pacific Islander community. Against the backdrop of these anti-Asian sentiments and actions, two tragic mass shootings occurred around this past Lunar New Year, of whom many of the victims were Asian. These tragic events and their devasting impacts on the community have highlighted the importance of understanding and addressing mental health needs among Asian and NHOPI people. Although overall rates of mental illness are generally lower among Asian people compared to White people, this finding may reflect underdiagnosis and underreporting. It also may mask variations in mental health among subgroups of the population. Among people with mental illness, Asian people are less likely to utilize mental health services compared to other racial and ethnic groups. In 2021, among adults with any mental illness in the past year, only 25% of Asian adults reported receiving mental health services compared to 52% of White adults (Figure 6). Data on utilization were not available for NHOPI people. Moreover, data show rising rates of suicide death among Asian and Pacific Islander adolescents (ages 12-17). Although they have lower rates of suicide deaths compared to their White peers, suicides were the leading cause of death among Asian and Pacific Islander children ages 10-14 and the second leading cause among those between the ages of 15 and 35 in 2020, and suicide death rates more than doubled among this population from 2010 (2.2 per 100,000) to 2020 (5.0 per 100,000).

In the wake of the COVID-19 pandemic, there has been a heightened awareness and focus on addressing health disparities, including recognizing the ongoing impacts of historic actions and policies on health disparities today. Anti-Asian racism is not new within the United States. Anti-Asian sentiments and related Sinophobia are embedded in U.S. history, as evidenced by the implementation of the Chinese Exclusion Acts in the late 1800s and the incarceration of Japanese Americans in the twentieth century. Historical actions have also contributed to ongoing trauma and negative health outcomes for NHOPI people. In the 19^th century, the U.S. began substantial expansion across the Pacific Ocean which included the colonization of many of the Pacific Islands, and the overthrow of the Hawaiian monarchy. Since occupation, the United States’ colonial, post-colonial, and military actions in the region have resulted in adverse socioeconomic, health, and environmental pollution-related legacies among local and Indigenous populations. In addition to these historic actions and their aftermath, Asian and NHOPI people have faced ongoing stresses associated with the perpetual foreigner and model minority stereotypes, and acculturation.

The federal government has taken several actions focused on advancing health equity broadly and in response to the rise in Asian hate and anti-Asian violence, specifically. Early in his presidency, President Biden issued a series of executive orders focused on advancing health equity, including orders that outlined equity as a priority for the federal government broadly and as part of the pandemic response and recovery efforts. Federal agencies were directed with developing Equity Action Plans that outlined concrete strategies and commitments to addressing systemic barriers across the federal government. In 2021, Congress enacted the COVID-19 Hate Crimes Act in response to the increase in anti-Asian violence during the pandemic. During that time, the Biden Administration also released Executive Order 14031 “Advancing Equity, Justice, and Opportunity for Asian Americans, Native Hawaiians, and Pacific Islanders,” which established the White House Initiative on Asian Americans, Native Hawaiians, and Pacific Islanders (WHIAANHPI). The WHIAANHPI is committed to advancing equity for Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) by investing in AANHPI communities and responding to the spikes in anti-Asian violence. In January 2023, the White House announced its National Strategy to Advance Equity, Justice, and Opportunity for Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) Communities.

As part of efforts to address disparities and advance health equity, there are efforts underway to expand and improve availability of disaggregated data, including for Asian and NHOPI people. As shown in this analysis, Asian and NHOPI people have diverse characteristics and experiences that influence their health and health care. These differences point to the importance of having disaggregated data for Asian and NHOPI groups to identify disparities and direct efforts to address them. The Biden Administration has charged the government with addressing the systemic lack of disaggregated AANHPI data in federal statistical systems. The Interagency Working Group on Equitable Data in collaboration with the WHIANHPI is also working to improve research on policy and program outcomes for AANHPI communities. In April 2022, the working group released its Equitable Data Working Group Report, which highlighted the need to generate disaggregated data, increase access to disaggregated data, conduct equity assessments of federal programs, and emphasize accountability to communities in the United States. The Office of Management and Budget released proposals in January 2023 to update the minimum standards for collecting and presenting data on race and ethnicity for all federal reporting, including providing a separate racial category for people who identify as Middle Eastern or North African and moving to collect race and ethnicity through a combined single question instead of asking about Hispanic or Latino ethnicity in a separate question from race.

Appendix

Figure 4a: Share of All Nonelderly Uninsured Asian People, 2021

Figure 4b: Share of Nonelderly Uninsured Asian Citizens, 2021

Figure 4c: Share of Nonelderly Uninsured Asian Noncitizens, 2021

Figure 4d: Share of All Nonelderly Uninsured NHOPI People, 2021

Figure 4e: Share of Nonelderly Uninsured NHOPI Citizens, 2021

Figure 4f: Share of Nonelderly Uninsured NHOPI Noncitizens, 2021

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A KFF survey of Medicaid enrollees largely fielded prior to states resuming their efforts to redetermine Medicaid enrollees’ eligibility reveals many enrollees are unprepared for the renewal process that could result in some losing their coverage either due to eligibility changes or paperwork issues.

During the COVID-19 pandemic, states suspended their Medicaid eligibility renewals in exchange for additional federal funding, ensuring continuous health coverage for enrollees. States recently have resumed eligibility renewals and as of April 1 could start to disenroll people who either no longer qualify or who do not complete the renewal process.

The survey found that nearly two-thirds (65%) of Medicaid enrollees were unsure whether states could remove people from the program if they no longer meet the eligibility requirements or don’t complete the renewal process. An additional small share (7%) incorrectly believe that states couldn’t do this.

More than four in 10 enrollees whose sole coverage is Medicaid say that if the state told them they were no longer eligible for Medicaid coverage, they would not know where to look for other coverage (27%) or end up uninsured (15%).

Other findings include:

• Nearly half (47%) of Medicaid enrollees say they have not previously been through the Medicaid renewal process, including two-thirds (68%) of Medicaid enrollees who are 65 and older. This group may be less likely to understand the importance of completing the renewal paperwork to maintain their coverage.

• A third (33%) of enrollees say they have not provided updated contact information to their state Medicaid agency in the past year. Some in this group may miss critical eligibility renewal notices that would require action on their part to maintain coverage.

• About half (52%) of enrollees say they prefer to get Medicaid information via the U.S. mail, which is the primary way most states contact enrollees, though nearly half of enrollees say they would prefer to get Medicaid information another way – through email (29%), an online portal (11%), or text messages (8%).

• About a third of Medicaid enrollees say they have had a change in income or other change that could now make them ineligible for Medicaid or are unsure if they have had such a change, but most enrollees (65%) say their circumstances have not changed, suggesting they are still eligible. Those who are still eligible could lose coverage if they don’t complete the renewal process.

• The vast majority (85%) say that it would be useful if they had a navigator to help with the renewal process and look for other coverage if needed.

Designed and analyzed by public opinion researchers at KFF, the survey was conducted February 21-March 14, 2023, online and by telephone among a representative sample of 3,605 adults in the U.S. with health insurance coverage, including 1,212 individuals with Medicaid coverage. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 4 percentage points for those with Medicaid coverage. For results based on other subgroups, the margin of sampling error may be higher.

During the COVID-19 pandemic, the U.S. population experienced the most significant two-year decline in life expectancy in roughly a century, according to new research by KFF, with data showing that COVID-19 deaths disproportionately impacted people of color and exacerbating longstanding racial disparities in life expectancy. While overall U.S. life expectancy declined by 2.7 years between 2019 and 2021, American Indian and Alaskan Native (AIAN) people experienced a decline of 6.6 years, Hispanic people and Black people dropped 4.2 and 4 years, respectively, compared to a decline of 2.4 years for White people and 2.1 years for Asian people

Cancer and heart disease continue to be the leading causes of death for the U.S. population and in 2020 COVID-19 joined them in the ranks, but the pandemic has coincided with other increases in causes of death. Liver disease rose to the ninth leading cause of death in 2021, reflecting a rise in alcohol-related deaths, with AIAN people experiencing the most significant increase in this cause of death.Increases in drug overdose deaths were a major factor in the rise of unintentional injury deaths from 2019 to 2021, although its ranking did not fluctuate much within racial groups.

While suicide’s ranking among the leading causes of death fell from 2019 to 2021, there was a significant increase in suicides among Black and White people and AIAN men.Provisional 2022 data indicate a decrease in overall mortality from 2021, reflecting declines in COVID-19 deaths overall. However, AIAN and Black people continue to have higher COVID-19 death rates than White people.Read the brief for a discussion about addressing underlying drivers of U.S. life expectancy racial disparities, including inequities in health insurance coverage, access to care, and social and economic factors that drive health.

Introduction

Amid the COVID-19 pandemic, life expectancy in the U.S. declined 2.7 years between 2019 and 2021, from 78.8 years to 76.1 years, marking the largest two-year decline in life expectancy since the 1920’s. This decline further widened the existing gap in life expectancy between the U.S. and other comparably large and wealthy countries. It also exacerbated longstanding racial disparities in life expectancy and mortality within the U.S., contributing to excess deaths and increased costs. This analysis examines trends in life expectancy and leading causes of death by race and ethnicity and discusses the factors that contribute to racial disparities in life expectancy. In sum, it finds:

• There was a sharp drop-off in life expectancy between 2019 and 2021, with particularly large declines among some groups. American Indian and Alaska Native (AIAN) people experienced the largest decline in life expectancy of 6.6 years during this time, followed by Hispanic and Black people (4.2 and 4.0 years, respectively).
• Reflecting these declines, provisional data for 2021 show that life expectancy was lowest for AIAN people at 65.2 years, followed by Black people, whose expectancy was 70.8 years, compared with 76.4 years for White people and 77.7 years for Hispanic people. It was highest for Asian people at 83.5 years. Data were not reported for Native Hawaiian and Other Pacific Islander (NHOPI) people.
• These declines were largely due to COVID-19 deaths and reflect the disproportionate burden of excess deaths, including premature excess deaths (before age 75), among people of color during the pandemic. Although COVID-19 mortality was a primary contributor to the recent decrease in life expectancy across groups, leading causes of death vary by race and ethnicity.

These recent stark declines and widening racial disparities in life expectancy amplify the importance of addressing underlying drivers of these disparities, including inequities in health insurance coverage and access to care and social and economic factors that drive health.

Trends in Life Expectancy by Race/Ethnicity

Life expectancy at birth represents the average number of years a group of infants would live if they were to experience throughout life the age-specific death rates prevailing during a specified period. Life expectancy is one of the most used measures of population health, enabling comparisons in health status between countries, states, local communities, and demographic groups. Differences in life expectancy occur across a broad range of dimensions which often intersect with each other, including race, socioeconomic status, gender, geography, and other characteristics. For example, In the U.S. and all other comparable countries, men tend to have shorter life expectancy at birth than women. In 2021, life expectancy for women in the U.S. was 5.9 years higher than for men (79.1 years vs. 73.2 year, respectively), and similar gender disparities persisted within racial and ethnic groups. This analysis focuses on differences in life expectancy by race and ethnicity overall, but within racial and ethnic groups there is variation by these other factors, such as gender.

Prior to 2015, there were relatively steady increases in life expectancy in the U.S., but racial disparities persisted. Before 2015, life expectancy in the U.S. steadily increased with an overall gain of about 10 years between 1960 and 2015 from 69.7 years to 79.4 years. While there have been large gains in life expectancy across racial and ethnic groups, racial disparities have been longstanding and persisted over time. Black people have consistently had lower life expectancy than White people, while, conversely, Hispanic people have consistently had longer life expectancy compared to White people. When life expectancy reached its peak in 2014, life expectancy for Black people was more than three years shorter than White people (75.3 vs. 78.8 years), and Hispanic people had a longer life expectancy at 82.1 years (Figure 1 and Appendix Table 1). (Data were not available for other groups.)

Following this peak in 2014, life expectancy declined for the first time in over two decades. Between 2014 and 2017, overall life expectancy declined by 0.3 years with a slightly larger decline for Black people (0.4 years) compared with Hispanic and White people (0.3 years for both) (Figure 1 and Appendix Table 1). Separate data were not reported for Asian, AIAN and NHOPI people for this period. Research suggests that increases in mortality due to suicide, drug overdose and alcohol abuse were drivers of the decreasing life expectancy during this time. In 2018 and 2019, life expectancy remained relatively stable overall and across groups.

Life expectancy sharply declined by 2.7 years between 2019 and 2021, and disparities widened amid the COVID-19 pandemic (Figure 2). In 2019, prior to the onset of the pandemic, overall life expectancy was 78.8 years. AIAN people had the lowest life expectancy at 71.8 years, followed by Black people at 74.8. These groups both had lower life expectancies than White people, whose life expectancy was 78.8 years. Hispanic and Asian people had longer life expectancies of 81.9 and 85.6 years, respectively. The onset of the COVID-19 pandemic in 2020 resulted in higher mortality rates. Because life expectancy is based on death rates for a given period, these increased mortality rates drove declines in life expectancy in 2020 and 2021. Overall life expectancy declined by 2.7 years between 2019 and 2021, with AIAN people experiencing the largest life expectancy decline of 6.6 years, followed by Hispanic and Black people (4.2 and 4.0 years, respectively), and a smaller decline of 2.4 years for White people. Asian people had the smallest decline in life expectancy of 2.1 years between 2019 and 2021. These declines further widened gaps in life expectancy for AIAN and Black people compared to White people and reduced the advantage in life expectancy for Hispanic people relative to White people. As of 2021, provisional data show that life expectancy was lowest for AIAN and Black people at 65.2 years and 70.8 years, respectively, compared to 76.4 years for White people and 77.7 years for Hispanic people. It was highest for Asian people at 83.5 years. Data were not available for NHOPI people. Given that life expectancy reflects death rates from a specified year and provisional data from 2022 show that overall mortality declined 5.3% between 2021 and 2022, reflecting a fall-off in COVID-19 deaths, there may be small increases in life expectancy in upcoming years.

Causes of Recent Life Expectancy Declines

The declines in life expectancy between 2019 and 2021 largely reflect an increase in excess deaths amid the COVID-19 pandemic, which disproportionately impacted Black, Hispanic, and AIAN people. KFF analysis finds the pandemic was associated with faster rises in premature mortality rates and resulted in more excess years of life lost for people of color compared to their White counterparts, with people of color accounting for 59% of excess years of life lost while making up 40% of the population. Other analysis further finds that COVID-19 mortality had the largest contribution to the decline in life expectancy between 2020 and 2021 among AIAN, Black and White people, accounting for 21.4%, 35.0%, and 54.1% of their declines, respectively. Among Hispanic and Asian people, COVID-19 had the second largest contribution to the decline in life expectancy, accounting for 25.5% and 16.6% of their declines, respectively. The largest contributor to the decline for Hispanic people was an increase in mortality due to unintentional injuries, while growth in cancer deaths was the primary contributor to the decline for Asian people between 2020 and 2021.

Although COVID-19 mortality was a primary contributor to the recent decrease in life expectancy across groups, leading causes of death varied by race and ethnicity. Overall, COVID-19 was the third leading cause of death in 2021, after heart disease and cancer. However, COVID-19 was the top leading cause of death for Hispanic and AIAN people, followed by heart disease and cancer (Figure 3). Among Black, Asian, and White people, COVID-19 was the third leading cause of death, outranked by heart disease and cancer.

Beyond COVID-19 becoming a leading cause of death, there were other changes in leading causes of death that occurred during the pandemic (Figure 3). For example, flu activity has been lower since the beginning of the pandemic, leading to flu and pneumonia falling out of the ten leading causes of death in 2021. In contrast, liver disease rose to the ninth leading cause of death, reflecting sharp increases in alcohol-related deaths during the pandemic, with AIAN people experiencing the largest increase from 44.7 per 100,00 in 2019 to 77.8 per 100,000 in 2021. Deaths related to unintentional injuries also increased between 2019 and 2021, largely driven by increases in drug overdose deaths. Although suicide rates dropped out of the top ten leading causes of death overall during the pandemic (10^th leading cause of death in 2019 vs. 11^th in 2021), there was a significant increase in suicide deaths between 2020 and 2021 among Black and White men and women and AIAN men, and suicide remained the ninth leading cause of death for AIAN people and the tenth leading cause for White people in 2021. Although homicide deaths increased between 2020 and 2021, Black people are the only racial group for which homicide was a top ten cause of death in 2021, reflecting high rates of homicide among young Black men. For example, homicide was the leading cause of death in 2021 among Black males ages 15-34, and the death rate was 20 times higher than their White counterparts (126.1 per 1000,000 vs. 6.1 per 100,000), continuing a disparity in homicides that has existed for decades.

Provisional data from 2022 show that overall mortality declined 5.3% between 2021 and 2022, and that, in 2022, the three leading causes of death were heart disease, cancer, and unintentional injuries. During this time, COVID-19 deaths declined almost 50% overall and across all racial and ethnic groups, dropping to the fourth leading cause of death. Despite these declines in COVID-19 deaths, AIAN and Black people continued to have higher COVID-19 death rates compared to White people. Declining death rates from COVID-19 may improve life expectancy overall, however racial gaps will likely persist given the continued disparities in COVID-19 and other leading causes of death.

Factors Contributing to Racial Life Expectancy Disparities

Research suggests that the factors driving disparities in life expectancy are complex and multifactorial. They include differences in health insurance coverage and access to care, social and economic factors, and health behaviors that are rooted in structural and systemic racism and discrimination (Figure 4).

People of color are more likely than their White counterparts to be uninsured and to face other barriers to accessing health care that may contribute to shorter life expectancy. Data show that people of color are less likely to have health insurance and more likely to face barriers to accessing care, such as not having a usual source of care. Among AIAN people, chronic underfunding of the Indian Health Service further contributes to barriers to health care. Research shows that, overall, uninsured people are more likely than those with insurance to go without needed medical care due to cost and less likely to receive preventive care and services. Research further shows that uninsured people have higher mortality rates and lower survival rates than people with insurance.

Underlying social and economic inequities also drive disparities in mortality and life expectancy. Hispanic, AIAN, and Black people are more likely to have lower incomes and educational attainment levels compared to White people, and studies find that people with higher incomes and more education live longer lives. Other social and economic factors may also affect life expectancy. For example, historic housing policies, including redlining, and ongoing economic inequities have resulted in residential segregation that pushed many low-income people and people of color into segregated urban neighborhoods. Research finds that living in racially segregated neighborhoods is associated with shorter life expectancy and higher mortality rates for Black people.

Social and economic factors can also shape health behaviors and exposure to health risks that influence life expectancy,  For example, Black and AIAN people  have higher rates of smoking, substance and alcohol use disorders, and obesity compared to White people. Research suggests that eliminating smoking and obesity would greatly narrow disparities in life expectancy between Black and White people. People of color are also disproportionately affected by violence, including police and gun-related violence. Research shows African American and AIAN men and women and Latino men are at increased risk of being killed by police compared to their White peers. Black and Hispanic adults also are more likely than White adults to worry about gun violence according to 2023 KFF survey data. Other KFF analysis shows that firearm death rates increased sharply among Black and Hispanic youth during the pandemic driven primarily by gun assaults and suicide by firearm.

Research also highlights the role of racism and discrimination in driving racial disparities in mortality. Many of the inequities described above are rooted in racism and discrimination. Racism also contributes to lower quality of care among people of color. For example, a KFF/The Undefeated survey found that most Black adults believe the health care system treats people unfairly based on their race, and one in five Black and Hispanic adults report they were personally treated unfairly because of their race or ethnicity while getting health care in the past year. Beyond driving structural inequities and differences in experiences obtaining health care, research also demonstrates that racism and discrimination have direct negative impacts on health. For example, research finds that the cumulative effects of exposure to racism and chronic stress, referred to as allostatic load, may contribute to a more rapid decline in health and higher mortality among Black people. The health of AIAN people has also been negatively affected by ongoing racism and discrimination, and intergenerational trauma stemming from historical actions and policies, including genocide, removal from native lands, and assimilation efforts, including Indian boarding schools.

Some life expectancy patterns are not fully understood or observable in the data presented. Notably, Hispanic people have longer life expectancy than their White counterparts despite experiencing increased barriers to accessing health care and social and economic challenges typically associated with poorer health outcomes. Researchers have hypothesized that this finding, sometimes referred to as the Hispanic or Latino health paradox, in part, may stem from variation in outcomes among subgroups of Hispanic people by origin, nativity, and race, with better outcomes for some groups, particularly recent immigrants to the U.S. However, the findings still are not fully understood. Measures of life expectancy for Asian people as a broad group may mask underlying differences among subgroups of the population who vary across health access and social and economic factors. Research has shown variation in life expectancy among Asian subgroups, with Chinese people having the longest life expectancy and Vietnamese people having the shortest life expectancy, which may in part reflect differences in socioeconomic status. Additionally, data limitations for NHOPI people prevented the ability to include them in this analysis. Efforts to expand and improve data collection for NHOPI people will be important to gain a better understanding of their experiences, particularly since they suffered disproportionate impacts on mortality from COVID-19.

Conclusion

Overall, the data suggest that the COVID-19 pandemic exacerbated longstanding racial disparities in life expectancy. The recent declines and widening of disparities in life expectancy highlight the urgency and importance of addressing disparities in health broadly and increased attention to disparities in mortality and life expectancy specifically. Continued efforts within and beyond the health care system will be important to reduce ongoing racial disparities in life expectancy, many of which are rooted in systemic racism. Within the health care system, these may include ongoing efforts to reduce gaps in health insurance, increase access to care, and eliminate discrimination and bias. Beyond the health care system, addressing broader social and economic factors, including those that drive disparities in behavioral risks, will also be important.

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A new KFF analysis reviews exceptions to abortion bans and describes how the stated aim to provide life-saving and health-preserving abortion care may not be achieved in practice. Abortion is currently banned in 14 states and many other states have attempted to ban or severely restrict abortion access. Exceptions to state abortion bans generally fall into four general categories: to prevent the death of the pregnant person, when there is risk to the health of the pregnant person, when the pregnancy is the result of rape or incest, and when there is a lethal fetal anomaly.

• While the state bans and restrictions include life or health exceptions, the vagueness of the language describing them can effectively restrict the ability of clinicians to exercise their own medical judgement based on their expertise and accepted standards of care.

• Abortion bans and restrictions have led physicians to delay providing miscarriage management care. 
• Mental health exceptions are rare even though 20% of pregnancy-related deaths are attributable to mental health conditions. 
• Few state abortion bans contain exceptions for pregnancies resulting from rape or incest and law enforcement involvement is often required to document the sexual assault. 
• In states where there is more than one abortion ban, the exceptions can be at odds with each other, creating confusion among patients and providers.  

Read the brief, “A Review of Exceptions in State Abortions Bans: Implications for the Provision of Abortion Services” to learn more about how exceptions to abortion bans impact access to abortion care for people across the United States.