"4 ASPE |grmisser FACT SHEET PLANNING AND EVALUATION September 25' 2023 -Inflation Reduction Act Research Series- Projected Impacts for Latino Medicare Enrollees The Inflation Reduction Act (IRA) is helping people with Medicare, including the 5.3 million Part D enrollees who identify as Latino. Our review shows that in 2020, about 131,000 Latino enrollees would have benefitted from the IRA's $35 insulin cap and in 2021, about 245,000 Latinos would not have had any out-of-pocket costs for recommended Part D covered adult vaccines. Under the IRA's Part D redesign, nearly 73,000 Latino enrollees who do not receive financial assistance are projected to save $1,000 or more in 2025. Additional benefits are expected for this population from other IRA drug-related provisions. KEY POINTS e Latino" Medicare enrollees have disproportionately higher rates of certain health conditions relative to their non-Latino peers, including higher rates of hypertension and diabetes. They also report greater health care cost related problems and difficulty affording prescription drugs than their White counterparts. e In 2024, under the IRA, expansion of low-income subsidy (LIS)" eligibility goes into effect, which could result in a reduction of about $300 in average annual out-of-pocket costs for eligible enrollees from all racial and ethnic groups.! In 2021, about 38,000 Latino Medicare enrollees received partial LIS benefits. This provision is expected to expand full LIS benefits to these individuals and others who meet the expanded eligibility criteria under the IRA. e The IRA caps the monthly out-of-pocket costs for each covered insulin product to $35, which may result in greater access to and affordability of insulin for Latino enrollees.* This provision went into effect in January 2023 for covered insulin products under Part D and July 2023 for covered * This fact sheet uses the term "Latino" to refer to all individuals of Hispanic and Latino origin. " For eligible enrollees whose income and resources are limited, the Medicare Prescription Drug, Improvement and Modernization Act of 2003 established extra help for prescription drugs. Subsidies are paid by the Federal government to drug plans and provide assistance with premiums, deductibles, and co-payments. * The $35 cap for a month's supply of each covered insulin product went into effect for Part D enrollees on January 1, 2023 and for Part B covered insulin on July 1, 2023. aspe.hhs.gov 1 insulin products under Part B. Under Medicare Part B and Part D, about 131,000 Latino Medicare enrollees would have benefited from the insulin cap if it had been in effect in 2020. e The IRA vaccine provision made recommended Part D covered adult vaccines available without enrollee cost-sharing starting on January 1, 2023. Among the 3.4 million enrollees who received a vaccine under Medicare Part D in 2021, nearly 245,000 were Latino enrollees. These enrollees would have had no out-of-pocket costs under the IRA vaccine provision if it had been in effect in 2021. e The annual $2,000 out-of-pocket cap that takes effect in 2025 and is indexed to inflation annually thereafter is expected to help enrollees who take high-priced drugs, including Latino enrollees, who have higher rates of certain health conditions that require costly medications {e.g., diabetes). e Among Latino non-LIS enrollees projected to have out-of-pocket savings under the IRA's Part D redesign provisions, a sizeable number will have savings of $1,000 or more in out-of-pocket costs: about 73,000, or 3 percent of all Latino non-LIS enrollees, are estimated to save an average of $2,500 on average annual out-of-pocket prescription drug costs in 2025. e Of the 10 drugs covered under Part D selected for participation in the Medicare Drug Price Negotiation Program for initial price applicability year 2026, the share of enrollees using these drugs that are Latino is highest for Januvia (16 percent), a proportion that is 6 percentage points greater than Latino representation in the Part D population {10 percent).? BACKGROUND The Inflation Reduction Act (IRA) is improving affordability of prescription drugs for all Medicare enrollees through a variety of drug related provisions, including:" e capping out-of-pocket spending for prescription drugs covered under Part D, e improving coverage of certain drugs including insulin and vaccines, e expanding eligibility for financial assistance, e changing the Part D benefit structure, and e authorizing the Secretary of Health and Human Services to negotiate prices directly with participating manufacturers for selected drugs that have high total spending and are high expenditure, single source drugs without generic or biosimilar competition. This fact sheet outlines the potential impacts of the IRA's key drug-related provisions for Latino Medicare enrollees. Medicare Enroliment * For a complete list of IRA drug-related provisions, please see: Inflation Reduction Act and Medicare | CMS September 2023 FACT SHEET 2 About 10 percent of the 65 million Americans enrolled in Medicare reported their race as Latino" (about 6.5 million people).® About 53 million Medicare enrollees have Part D prescription drug coverage, of whom 10 percent - about 5.3 million - are Latino. %* Health Status and Access to Care Among Latino Americans Latino Medicare enrollees have disproportionately higher rates of adverse health-related outcomes relative to their non-Latino peers some health conditions. For example, among this population: e About 37 percent of Latino Medicare enrollees report being in fair or poor health compared to 21 percent of White enrollees.® ¢ Latino enrollees have higher rates of diabetes than White enrollees (37 percent versus 24 percent for White Medicare enrollees)." e Alarger share of Latino Medicare enrollees (65 percent) have . hypertension than White Medicare enrollees (60 percent).? Latino adults over the age of e Alarger share of Latino Medicare enrollees report having 65 report difficulty affording limitations in activities of daily living (33 percent) and i s e : rescription medications at cognitive impairment (28 percent) compared to White p P Medicare enrollees {27 percent and 19 percent, rates 1.5 to 2 times higher respectively).' than White adults. e Alarger share of Latino enrollees are report problems paying medical bills compared to White enrollees {13 percent vs. 9 percent).1® e Latino adults over the age of 65 report difficulty affording prescription medications at rates roughly 1.5 to 2 times higher than White adults.! PROJECTED IMPACTS OF THE IRA'S DRUG-RELATED PROVISIONS Below, we highlight some key Medicare drug-related provisions of the IRA and their projected impacts for Latino enrollees. Expansion of Financial Assistance through the Low-Income Subsidy (LIS) Program The Medicare Part D Low-Income Subsidy (LIS) assists enrollees who meet income and asset limits to pay for their Part D covered drugs. Prior to the IRA, in order to be eligible for full LIS, an enrollee must have income below 135 percent of the Federal Poverty Level (FPL), or $19,683 per year for an individual.*2 Enrollees are eligible for partial assistance if their incomes are between 135 and 150 percent of FPL. Beginning in 2024, the IRA expands full LIS benefits to individuals with incomes between 135 and 150 percent of FPL. Through full LIS benefits, eligible low-income people with Medicare can benefit from no deductible, no premium, and low, fixed copayments for covered Part D medications. The partial LIS benefits being phased out by the IRA include a premium paid on a sliding scale and higher coinsurances for covered prescription drugs. * Race and ethnicity is reported in Medicare claims data, however, there are limitations as outlined here: Quality of race and ethnicity data in Medicare - PubMed (nih.gov). " This is in addition to meeting asset requirements. For details on the LIS and partial LIS program, please see here: Limited Income and Resources | CMS September 2023 FACT SHEET 3 Projected Impact: Over 300,000 Medicare enrollees across all race and ethnicity groups receive partial LIS benefits.'31* Analysis suggests that expansion of LIS eligibility to 150 percent of FPL could result in a reduction of average annual out-of-pocket costs for these enrollees by $300.%> In 2021, about 38,000 Latino Medicare enrollees received partial LIS benefits.® This provision is expected to extend full LIS benefits to these individuals and others who meet the expanded eligibility criteria under the IRA.Y' Out-of-Pocket Spending Capped at $35 for a Month's Supply of each Insulin Under the IRA, insulin is capped at $35 for a month's supply of each covered insulin product; this provision went into effect in January 2023 for covered insulin under Part D and July 2023 for covered insulin under Part B. Prior to the IRA, there was no cap on out-of-pocket costs for insulin products under Medicare Part B or Part D." Taking insulin if it is prescribed is critical to controlling diabetes, however, patients may ration their insulin if they cannot afford it.'® Consequences of uncontrolled diabetes among Latino patients include hospitalizations and adverse health events. In 2019, there were 853,880 hospitalizations that had a principal diagnosis of diabetes, of which about 16 percent were among Latino patients; this estimate highlights the burden of diabetes-related complications among this population-®* Projected Impact: The IRA will cap monthly out-of-pocket costs for insulin to $35 for each covered insulin product. This reduction may result in greater access to insulin for Latino enrollees. Under Medicare Part B and Part D, about 131,000 Latino Medicare enrollees would have benefited from the insulin cap if it had been in effect in 2020.%° The reduction in out-of-pocket spending, in turn, may improve access and adherence to prescribed insulin regimens, which may avert hospitalizations and health care complications associated with uncontrolled diabetes*. Elimination of Copays for Recommended Part D Covered Vaccines Under the IRA, beginning in 2023, enrollees do not have to pay out-of-pocket costs for adult vaccines covered under Part D that are recommended by the Advisory Committee on Immunization Practices (ACIP). Prior to the IRA, Part D covered vaccines including shingles, tetanus and diphtheria, pertussis, hepatitis A, hepatitis B, and others were subject to out-of-pocket costs. Vaccination rates among adults, including older adults, are generally low, and these rates are even lower among Latino adults. For example, Latino Medicare enrollees have lower rates of shingles vaccination than White enrollees (36 percent of Latinos are vaccinated compared to 58 percent of White enrollees).* Projected Impact: The IRA provides access to recommended adult vaccines covered under Medicare Part D without any out-of-pocket costs. Among 3.4 million enrollees who received a vaccine under Medicare Part D in 2021, about 245,000 were Latino enrollees.?? These enrollees paid a total of about $7.9 million in out-of- * The Part D Senior Savings Model required participating enhanced alternative Part D plans to offer insulin at reduced cost prior to the passage of the IRA. For more information on this Model, please see here: Part D Senior Savings Model | CMS Innovation Center " Hospitalizations were for diabetic ketoacidosis, hyperglycemia, chronic kidney disease, and end-stage renal disease. * There are many reasons why patients may not be able to follow prescribed insulin regimens and out-of-pocket costs are one factor. Please see the following for a more detailed discussion: aspe-insulin-affordibility-rtc.pdf (hhs.gov) September 2023 FACT SHEET 4 pocket costs for Part D covered vaccines, averaging about $32 per enrollee in 2021 across all Latino enrollees who received a Part D covered vaccine. These enrollees would not have had to pay out-of-pocket for recommended adult vaccines covered under Part D if the IRA vaccine provision had been in effect in 2021.% There are many factors that shape whether individuals are able to obtain recommended vaccinations, including out-of-pocket costs. 242526 Thus, this provision may increase accessibility of Part D covered vaccines for this population and will eliminate their out-of-pocket spending on Part D covered adult vaccines. Changes in Part D Benefit Design The IRA changes the Part D benefit design. Key changes include: 1) in 2024, eliminating cost-sharing in the catastrophic coverage phase that requires patients to pay 5 percent of their drug costs and 2) in 2025, imposing a $2,000 out-of-pocket cap that is indexed to inflation annually and eliminating the coverage gap phase. It also limits annual increases in Part D premiums and allows enrollees to spread their out-of-pocket prescription costs over the year. Projected Impact: The Part D redesign, which includes provisions that eliminate the coverage gap phase and impose a maximum out-of-pocket cap of $2,000 in 2025 and indexed to inflation annually thereafter, is expected to help all enrollees, but especially those who have the highest out-of-pocket drug spending for diseases such as cancer, hypertension, diabetes, and others. Latino Medicare enrollees have higher rates of serious health conditions such as some types of cancer, diabetes, and hypertension and are expected to benefit from these provisions.?"® In 2025, the out-of-pocket cap and other Part D related provisions in the IRA are projected to save Latino enrollees an average of 33 percent in out-of-pocket costs, which translates to about $88 annually for each enrollee. ?® Among Latino non-LIS enrollees projected to have out-of-pocket savings under the IRA, a sizeable number will have savings of $1,000 or more in out-of-pocket costs: nearly 73,000, or 3 percent of Latino non- LIS enrollees, are estimated to save an average of about $2,500 on out-of-pocket prescription drug costs.3° Negotiation for Selected Drugs for Initial Price Applicability Year 2026 Under the IRA, the Secretary of the Department of Health and Human Services (HHS) is authorized to directly negotiate the prices of certain high expenditure, qualifying single source drugs without generic or biosimilar competition with participating manufacturers.3! The 10 drugs selected for negotiation for initial price applicability year 2026 are presented in Table 1 below along with the common conditions they treat, the total number of Medicare Part D enrollees taking the drug in calendar year 2022, and the percent of enrollees taking the drug who identify as Latino. Projected Impact: The projected impact of the negotiation for the selected drugs for initial price applicability year 2026 is not yet available. However, existing analysis shows that the share of enrollees taking one of the selected 10 drugs for initial price applicability year 2026 that are Latino ranges from a low of 5 percent for Imbruvica to a high of 16 percent for Januvia.??" About 16 percent of enrollees taking Januvia are Latino, which is 6 percentage points greater than Latino representation in the Part D population (10 percent).33 "For complete details, please see here: ASPE-IRA-Drug-Negotiation-Fact-Sheet-9-13-2023.pdf (hhs.gov) September 2023 FACT SHEET 5 Table 1. Medicare Part D Enrollees' Calendar Year 2022 Use of Drugs Selected for Negotiation for Initial Price Applicability Year 2026 Total Number of Share of Enrollees Medicare Part D Taking Each Drug Enrollees Taking the | that are Latinoin Drug Name Commonly Treated Conditions Drug in CY 2022 CY 2022 Eliquis Prevention and treatment of blood clots 3,505,000 6% Jardiance Diabetes; Heart failure 1,321,000 13% Xarelto Prevention and treatment of blood clots; 1,311,000 7% Reduction of risk for patients with coronary or peripheral artery disease Januvia Diabetes 885,000 16% Farxiga Diabetes; Heart failure; Chronic kidney 639,000 14% disease Entresto Heart failure 521,000 9% Enbrel Rheumatoid arthritis; Psoriasis; Psoriatic 47,000 14% arthritis Imbruvica Blood cancers 22,000 5% Stelara Psoriasis; Psoriatic arthritis; Crohn's 20,000 7% disease; Ulcerative colitis Fiasp; Fiasp Diabetes 763,000 11% FlexTouch; Fiasp PenfFill; Novolog; Novolog FlexPen; Novolog PenfFill Source: Available from: ASPE-IRA-Drug-Negotiation-Fact-Sheet-9-13-2023.pdf (hhs.gov) Notes: Percentages are calculated for Latinos using the total number of enrollees taking the drug as the denominator. ASPE estimates may differ from drug use figures reported by CMS due to differences in the time period that is examined. The drug use estimates are for Part D enrollees using the drug and not limited to those using the drug for the conditions shown in this Table. CONCLUSION The IRA includes provisions to increase accessibility and affordability of prescription drugs for Medicare enrollees, reduce the rate of growth in Medicare drug spending, and improve the financial sustainability of the Medicare program. This fact sheet reviews the projected impacts of key IRA provisions for Latino Medicare enrollees. Findings are promising, suggesting that the IRA Medicare drug-related provisions are projected to improve the affordability of medications for Latino enrollees. September 2023 FACT SHEET 6 REFERENCES ! Cubanski, J., Neuman, T., Freed, M., & Damico, A. How Will the Prescription Drug Provisions in the Inflation Reduction Act Affect Medicare Beneficiaries? Kaiser Family Foundation; 2022 2 Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Inflation Reduction Act Research Series: Medicare Enrollees' Use and Qut-of-Pocket Expenditures for Drugs Selected for Negotiation under the Medicare Drug Price Negotiation Program. (Fact Sheet No. HP-2023-21). September2023. 3 Centers for Medicare & Medicaid Services. "CMS Program Statistics - Medicare Part D Enrollment." 2021, Accessed 2023. Retrieved from: Search Data.CMS.gov - Centers for Medicare & Medicaid Services Data 4 Centers for Medicare & Medicaid Services. "CMS Program Statistics - Medicare Part D Enrollment." 2021, Accessed 2023. Retrieved from: Search Data.CMS.gov - Centers for Medicare & Medicaid Services Data 5 sayed, BA, Finegold, K, Olsen, TA, Ashok, K, Schutz, S, Sheingold, S, De Lew, N, Sommers, BD. Inflation Reduction Act Research Series: Medicare Part D Enrollee Out-Of-Pocket Spending: Recent Trends and Projected Impacts of the Inflation Reduction Act. (Issue Brief No. HP-2023-19). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. July 2023. § Ochieng, N., Cubanski, J., Neuman, T., Artiga, S., & Damico, A. Racial and ethnic health inequities and Medicare. Kaiser Family Foundation. February 16, 2021. 7 Centers for Medicare and Medicaid Services, (2021). Retrieved from: Diabetes Disparities in Medicare {cms.gov) 8 Ochieng, N., Cubanski, J., Neuman, T., Artiga, S., & Damico, A. Racial and ethnic health inequities and Medicare. Kaiser Family Foundation. February 16, 2021. % Ochieng, N., Cubanski, J., Neuman, T., Artiga, S., & Damico, A. Racial and ethnic health inequities and Medicare. Kaiser Family Foundation. February 16, 2021. 10 ochieng, N., Cubanski, J., Neuman, T., Artiga, S., & Damico, A. Racial and ethnic health inequities and Medicare. Kaiser Family Foundation. February 16, 2021. 11 Tarazi, W., Finegold, K., Sheingold, S., De Lew, N., and Sommers, BD. Prescription Drug Affordability among Medicare Beneficiaries (Issue Brief No. HP-2022-03). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. January 2022. 12 Centers for Medicare & Medicaid Services . (2023, February 9). 2023 Medicare Part D Low-Income Subsidy (LIS) Income and Resource Standards. Retrieved from https://www.cms.gov/files/document/2023medicarepartdlowincomesubsidylisincomeandresourcestandardsg.pdf 13 cybanski, J., Neuman, T., Freed, M., & Damico, A. How Will the Prescription Drug Provisions in the Inflation Reduction Act Affect Medicare Beneficiaries? Kaiser Family Foundation; 2022. 14 Centers for Medicare & Medicaid Services. "CMS Program Statistics - Medicare Part D Enrollment." 2021, Accessed 2023, 15 Cubanski, J., Neuman, T., Freed, M., & Damico, A. How Will the Prescription Drug Provisions in the Inflation Reduction Act Affect Medicare Beneficiaries? Kaiser Family Foundation; 2022. 16 Centers for Medicare & Medicaid Services. "CMS Program Statistics - Medicare Part D Enrollment." 2021, Accessed 2023. 17 Centers for Medicare & Medicaid Services. "CMS Program Statistics - Medicare Part D Enrollment." 2021, Accessed 2023. 18 Gaffney, A., Himmelstein, D. U., & Woolhandler, S. (2022). Prevalence and correlates of patient rationing of insulin in the United States: a national survey. Annals of Internal Medicine, 175(11), 1623-1626. 19 sayed, BA, Finegold, K, Ashok, K, Schutz, S, De Lew, N, Sheingold, S, Sommers, BD. Inflation Reduction Act Research Series: Medicare Part D Enrollee Savings from Elimination of Vaccine Cost-Sharing. (Issue Brief No. HP-2023-05). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. March 2023. September 2023 FACT SHEET 7 20 sayed, BA, Finegold, K, Ashok, K, Schutz, S, De Lew, N, Sheingold, S, Sommers, BD. Inflation Reduction Act Research Series: Medicare Part D Enrollee Savings from Elimination of Vaccine Cost-Sharing. (Issue Brief No. HP-2023-05). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. March 2023. 2 Ochieng, N., Cubanski, J., Neuman, T., Artiga, S., & Damico, A. {2021). Racial and ethnic health inequities and Medicare. Retrieved September, 20, 2023. 22 sayed, BA, Finegold, K, Ashok, K, Schutz, S, De Lew, N, Sheingold, S, Sommers, BD. Inflation Reduction Act Research Series: Medicare Part D Enrollee Savings from Elimination of Vaccine Cost-Sharing. (Issue Brief No. HP-2023-05). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. March 2023. 2 sayed, BA, Finegold, K, Ashok, K, Schutz, S, De Lew, N, Sheingold, S, Sommers, BD. Inflation Reduction Act Research Series: Medicare Part D Enrollee Savings from Elimination of Vaccine Cost-Sharing. (Issue Brief No. HP-2023-05). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. March 2023. 24 Tao, Z., Li, Y., Stemkowski, S., Johnson, K. D., Acosta, C. J., Zhang, D., & Fendrick, A. M. (2018). Impact of out-of-pocket cost on herpes zoster vaccine uptake: an observational study in a medicare managed care population. Vaccines, 6(4), 78. 25 Kolobova, 1., Nyaku, M. K., Karakusevic, A., Bridge, D., Fotheringham, 1., & O'Brien, M. (2022). Vaccine uptake and barriers to vaccination among at-risk adult populations in the US. Human vaccines & immunotherapeutics, 18(5), 2055422, 26 Gellin, B. G., Shen, A. K., Fish, R., Zettle, M. A., Uscher-Pines, L., & Ringel, J. S. (2016). The national adult immunization plan: strengthening adult immunization through coordinated action. American journal of preventive medicine, 51(6), 1079-1083. 27 Centers for Disease Control and Prevention. (n.d.). Hispanic or Latino People and Cancer. Retrieved from https://www.cdc.gov/cancer/health-equity/groups/hispanic-latino.htm 28 Centers for Disease Control and Prevention. (2015, May). Vital Signs: Hispanic Health. Retrieved September 2023, from https://www.cdc.gov/vitalsigns/pdf/2015-05-vitalsigns.pdf 29 sayed, BA, Finegold, K, Olsen, TA, Ashok, K, Schutz, S, Sheingold, S, De Lew, N, Sommers, BD. Inflation Reduction Act Research Series: Medicare Part D Enrollee Out-Of-Pocket Spending: Recent Trends and Projected Impacts of the Inflation Reduction Act. (Issue Brief No. HP-2023-19). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. July 2023 30 sayed, BA, Finegold, K, Olsen, TA, Ashok, K, Schutz, S, Sheingold, S, De Lew, N, Sommers, BD. Inflation Reduction Act Research Series: Medicare Part D Enrollee Qut-Of-Pocket Spending: Recent Trends and Projected Impacts of the Inflation Reduction Act. (Issue Brief No. HP-2023-19). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. July 2023 31 Inflation Reduction Act of 2022. Text - H.R.5376 - 117th Congress (2021-2022): Inflation Reduction Act of 2022 | Congress.gov | Library of Congress 32 office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Inflation Reduction Act Research Series: Medicare Enrollees' Use and Out-of-Pocket Expenditures for Drugs Selected for Negotiation under the Medicare Drug Price Negotiation Program. (Fact Sheet No. HP-2023-21). September2023. 33 Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Inflation Reduction Act Research Series: Medicare Enrollees' Use and Out-of-Pocket Expenditures for Drugs Selected for Negotiation under the Medicare Drug Price Negotiation Program. (Fact Sheet No. HP-2023-21). September2023. September 2023 FACT SHEET 8 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Assistant Secretary for Planning and Evaluation 200 Independence Avenue SW, Mailstop 447D Washington, D.C. 20201 For more ASPE briefs and other publications, visit: aspe.hhs.gov/reports SUGGESTED CITATION Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Inflation Reduction Act Research Series: Projected Impacts for Latino Medicare Enrollees (Issue Brief No. HP- 2023-24). September 2023. COPYRIGHT INFORMATION All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated. DISCLOSURE This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. Subscribe to ASPE mailing list to receive email updates on new publications: https://list.nih.gov/cgi-bin/wa.exe?SUBED1=ASPE-HEALTH-POLICY&A=1 For general questions or general information about ASPE: aspe.hhs.gov/about HP-2023-24 September 2023 FACT SHEET