United States
A high-income system where a national hospice insurance benefit, fast-growing hospital palliative care and specialist certification sit alongside tight opioid controls. Also the upper reference point on the opioid sales scale.
9 domains reviewed · 9 high-confidence · 1 dated estimate · 9 material gaps
WHO region: Americas. World Bank income group: Income group not yet retrieved.
- Domains reviewed
- 9 of 9
- Hospice: 4 of 4
- Backed by a primary document
- 0 of 9
- Open questions
- 10
- Sources behind this dossier
- 38
- Newest source 2026
Lessons from United States
- Guideline and legal exemptions for palliative care did not stop end-of-life opioid access from falling as controls tightened, and minority patients lost more. Track access for seriously ill patients directly when opioid rules change.252,254,257
- Tying the hospice benefit to a strict prognosis, enforced by audits, can discourage timely enrollment, and payment changes meant to shorten stays did not. Prognosis rules fit non-cancer illness poorly.263,264
- Specialist palliative care grew fast yet stayed concentrated in large, urban and inpatient settings. Growth does not guarantee fair access.260,261
- A specialist shortage may not recover without deliberately expanding training positions.267
- Requiring patients to give up curative treatment to enter hospice can delay enrollment, which led Medicare to test concurrent care.330
- Where reservation hospice is scarce, planning end-of-life care with the extended family unit and supporting home death can build on care families already give.483,484
- Training trusted church members as lay supporters is one route to reach African American families about end-of-life care.487,486
- Prescription monitoring mandates that exempt cancer patients avoided the fall in oncology opioid prescribing seen under mandates without an exemption.705
Palliative care
Is morphine available in United States?
Opioid supply. Is a therapeutic opioid physically available in the wards that need it? Every country on this question
- 737.51 MME per 1,000 people per daySOURCE-CHECKED · 2019 DATA
Opioid analgesic consumption, United States, 20193
Method: IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access. Last checked 2026-09-25.
Cite this figure:
Among Medicare patients dying of cancer, opioid use fell substantially from 2007 to 2017 while pain-related emergency visits rose. Black and Hispanic patients had persistently less access, and state mandates to check prescription monitoring data were linked to further reductions, larger for some minority groups.3,252,253,254
Did tighter prescribing rules cause the decline, and did pain control in hospice worsen?
Help answer it:Search PubMedHow does United States regulate opioids for pain?
Narcotics regulation. What licensing regime governs stocking and dispensing, and when did it last change? Every country on this question
National prescribing guidelines in 2016, updated in 2022, exclude palliative and end-of-life care, and the update warns against rigid application. Most states have enacted opioid limits aimed at acute pain; most exempt serious illness, but exemption language is often broad and some states have none.255,256,257
Who can prescribe morphine in United States?
Prescriber authority. Who is legally allowed to prescribe, and can that group be widened? Every country on this question
State scope-of-practice laws restrict nurse practitioners and often require physician supervision. Evidence on whether independent practice changes opioid prescribing conflicts, and none of it is specific to palliative care.258,259
May nurse practitioners and physician assistants prescribe the strongest opioids for hospice patients in each state?
Help answer it:Search PubMedHow does palliative care reach patients in United States?
Service delivery. Through what structure does care actually reach a patient at home? Every country on this question
Hospital palliative care programs grew to near-universal coverage in large hospitals, but access depends on geography and ownership. Specialist physicians are concentrated in cities and inpatient care, and deaths have shifted from hospital to home and community settings.260,261,262
How large is community and home-based palliative care outside hospice?
Help answer it:Search PubMedWho pays for palliative care in United States?
Financing. Who pays for the drug, the visit and the workforce? Every country on this question
Medicare pays for most hospice care and requires a certified prognosis of six months or less. Audits from 2014 and a 2016 two-tier payment did not shorten stays, and hospice remains carved out of private Medicare plans after a test of including it ended in 2024.263,264,265
How are non-hospice palliative services paid for across Medicaid and private insurers?
Help answer it:Search PubMedHow are palliative care clinicians trained in United States?
Training and recognition. What credential exists, who awards it, and does anyone recognize it? Every country on this question
Hospice and palliative medicine is a subspecialty sponsored by ten specialty boards, with the first examination in 2008. The specialist workforce billing Medicare grew, yet modeling projects a shortfall without more fellowship positions.266,267,261
How many board-certified palliative physicians and nurses are there relative to need?
Help answer it:Search PubMedHow does United States prevent opioid misuse without blocking pain relief?
Opioid safeguards. How are misuse and diversion controlled, and are treatment and naloxone available, without blocking pain relief? Every country on this question
Among Medicare decedents with poor-prognosis cancers, the share filling an opioid prescription near the end of life fell from 42.0% to 35.5% between 2007 and 2017, while pain-related emergency visits rose from 13.2% to 19.9%. Mandatory prescription monitoring without a cancer exemption was linked to fewer oncology patients receiving opioids, with no significant fall where states exempted cancer.252,705
How have the 2022 CDC guideline and state prescribing limits affected opioid access for people in hospice or with non-cancer serious illness, and how often do people receiving opioid agonist treatment get hospice care?
Help answer it:Search PubMedHow do children get palliative care in United States?
Children's palliative care. How do children with life-limiting conditions get palliative care and the medicines they need? Every country on this question
Among 54 US inpatient pediatric palliative care programs in 2018, only 37% met minimum staffing standards and 60% could not meet clinical demand. Medicaid concurrent care lets children in hospice continue curative treatment, but states implement it in widely varying ways.708,709,710
What share of the more than 55,000 US children who die each year receive pediatric palliative care or hospice, and how many children with private insurance have access to concurrent care?
Help answer it:Search PubMedHospice care in United States
How the hospice model works here, who can use it, who pays and who it reaches. Covered 4 of 4.
What does hospice care look like in United States?
Hospice model. What does hospice mean here, who runs it, and in what settings? Every country on this question
US hospice developed in the 1970s and is organized around the Medicare hospice benefit, delivered mostly by home-based agencies. For-profit ownership has grown, and almost half of Medicare hospice enrollees in 2011 received care from multiagency chains.330,332
Who can get hospice care in United States?
Hospice eligibility. Who can enter hospice, on what criteria, and how late do patients arrive? Every country on this question
Under the Medicare hospice benefit, patients need an estimated prognosis of 6 months or less and must forgo curative or disease-modifying treatment for the terminal illness. Stays are often short, with a median of 12 to 13 days in one large California health system.330,331,338
What is the current national median hospice length of stay among Medicare decedents?
Help answer it:Search PubMedWho pays for hospice care in United States?
Hospice funding. Who pays for hospice care: a public benefit, insurance, charity or families? Every country on this question
Medicare pays for hospice through the hospice benefit, and hospice expansion in nursing homes between 2004 and 2009 raised net Medicare spending by a mean $6,761 per decedent. Medicare applies an aggregate annual cap per hospice and does not cover custodial care, while most hospices report providing some charity care.334,333,335
How many people reach hospice in United States?
Hospice reach. How many dying people use hospice, and who is left out? Every country on this question
In a nationally representative cohort of older decedents, 25.8% used hospice only and 18.8% used both hospice and home health in the last six months of life. Among Medicare decedents with heart failure, 48.2% used hospice, with lower odds for Black, Hispanic, under-65 and Medicaid-eligible patients.337,336
What fills the gap in United States
How people get care outside formal services: families, faith communities, volunteers, health workers, healers, other medicines and charity. Described, not scored.
- Family caregiving
On Great Plains reservations, clinicians reported that only one of three Indian Health Service sites studied had hospice access, and extended family networks (tiospaye) carry day-to-day care of seriously ill relatives. Families may also bring traditional practices such as smudging to the bedside. Scope is 3 reservations in one region.483,484
Subnational evidence- Faith communities
African American older adults in Denver described their church as a trusted place for health resources and spiritual and social support during chronic illness. In one hospice study, community clergy offered connection to the congregation and a trusted person, while hospice chaplains focused on present needs, and the two rarely interacted.485,486
Subnational evidence- Volunteers and compassionate communities
A church-based program trained 37 lay members of 3 African American churches as comfort care supporters who visit ill congregants to talk about advance care planning and end-of-life care. Post-training, 94% felt prepared for the role; the evaluation was done by the curriculum developers.487
Single-site evidenceSelf-reported- Community health workers and home-based care
A medical respite home served homeless people approaching the end of life; among 20 residents surveyed, 90% had substance use disorders and symptom frequency was high. Many worried about receiving too little (55%) or too much (40%) care at the end of life.488
Single-site evidence
Sources cited here
- 3Ju C, Wei L, Man KKC, et al.
Global, regional and national trends in opioid analgesic consumption, 2015 to 2019. Lancet Public Health 2022;7:e335-46. DOI 10.1016/S2468-2667(22)00013-5.
- 252Enzinger AC, Ghosh K, Keating NL, et al.
US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life. Journal of Clinical Oncology 2021;39(26):2948-2958. Medicare decedents 2007 to 2017: end-of-life opioid use declined while pain-related emergency visits rose. Abstract read.
- 253Enzinger AC, Ghosh K, Keating NL, et al.
Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life. Journal of Clinical Oncology 2023;41(14):2511-2522. Persistent racial and ethnic inequities in end-of-life opioid access, not mediated by socioeconomic variables; urine drug screening expanded. Abstract read.
- 254Bao Y, Zhang H, Pinheiro LC, et al.
Prescription Monitoring Program Mandates and Opioids Dispensed to Patients Dying of Cancer. JCO Oncology Practice 2026:OP2500187. Mandates associated with modest reductions in opioids dispensed to decedents, larger for Black and Asian/Pacific Islander decedents; ten states. Abstract read.
- 255Dowell D, Haegerich TM, Chou R.
CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016. JAMA 2016;315(15):1624-1645. Applies outside active cancer treatment, palliative and end-of-life care; recommends reviewing prescription monitoring data. Government guideline. Abstract read.
- 256Dowell D, Ragan KR, Jones CM, et al.
CDC Clinical Practice Guideline for Prescribing Opioids for Pain: United States, 2022. MMWR Recommendations and Reports 2022;71(3):1-95. Updates the 2016 guideline; excludes sickle cell and cancer pain and palliative or end-of-life care; not to be applied as inflexible standards. Government guideline. Abstract read.
- 257Jones KF, Abdulhay LB, Orris SR, et al.
The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness. Journal of Pain and Symptom Management 2022;64(2):89-99. Most states enacted opioid limits focused on acute pain; most exempt serious illness, some do not, and exemption language is often broad. Abstract read.
- 258McMichael BJ.
Nurse Practitioner Scope-of-Practice Laws and Opioid Prescribing. Milbank Quarterly 2021;99(3):721-745. State scope-of-practice laws restrict nurse practitioners; no evidence independent practice increases opioid prescriptions. Not specific to palliative care. Abstract read.
- 259Lozada MJ, Raji MA, Goodwin JS, et al.
Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. Journal of General Internal Medicine 2020;35(9):2584-2592. Most nurse practitioners and physician assistants prescribe like physicians, with more high-dose outliers in independent-authority states. Not specific to palliative care. Abstract read.
- 260Dumanovsky T, Augustin R, Rogers M, et al.
The Growth of Palliative Care in U.S. Hospitals: A Status Report. Journal of Palliative Medicine 2016;19(1):8-15. Steady growth, near-universal in large hospitals; access uneven by geography and ownership. Authors from a field advocacy organization. Abstract read.
- 261Hu X, Jiang C, Fan Q, et al.
US Medicare Hospice and Palliative Medicine Physician Workforce and Service Delivery in 2008-2020. Journal of Pain and Symptom Management 2024;67(6):e851-e857. Workforce grew but concentrated in metropolitan and inpatient settings; outpatient share fell. Abstract read.
- 262Teno JM, Gozalo P, Trivedi AN, et al.
Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015. JAMA 2018;320(3):264-271. Hospital deaths fell and home or community deaths rose. Abstract read.
- 263Fine PG.
Hospice Underutilization in the U.S.: The Misalignment of Regulatory Policy and Clinical Reality. Journal of Pain and Symptom Management 2018;56(5):808-815. Medicare pays for most hospice care and requires a certified six-month prognosis; audits may delay access. Policy commentary. Abstract read.
- 264Gianattasio KZ, Power MC, Lupu D, et al.
Medicare Hospice Policy Changes and Beneficiaries' Rate of Live Discharge and Length-of-Stay. Journal of Pain and Symptom Management 2023;65(3):162-172. 2014 audits and 2016 two-tier payment did not reduce length of stay. Abstract read.
- 265Bellerose M, Ryan AM, Ankuda CK, et al.
Medicare Advantage Plan Spending and Payments Under the Hospice Carve-Out. JAMA Network Open 2025;8(8):e2527724. Hospice carved out to fee-for-service Medicare; the inclusion test ended December 2024. Abstract read.
- 266Lamba S, DeSandre PL, Quest TE.
Opportunities and Challenges Facing the Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine. Journal of Emergency Medicine 2016;51(6):658-667. Ten member boards of the American Board of Medical Specialties sponsor the subspecialty; first examination 2008. Abstract read.
- 267Kamal AH, Wolf SP, Troy J, et al.
Policy Changes Key To Promoting Sustainability And Growth Of The Specialty Palliative Care Workforce. Health Affairs 2019;38(6):910-918. Projected workforce decline without policy change; more fellowship positions could reverse it. Abstract read.
- 705Graetz I, Hu X, Ji X, et al.
The effect of cancer exemption in mandatory-access prescription drug monitoring programs among oncologists. JNCI Cancer Spectr 2023;7(2). Medicare Part D prescriber data for 9,746 oncologists, 2013-2019, comparing state PDMP mandates with and without cancer exemptions. Abstract read.
- 706Odom JN, Applebaum A, Bakitas MA, et al.
Availability of Family Caregiver Programs in US Cancer Centers. JAMA Netw Open 2023;6(10):e2337250. National survey of Commission on Cancer-accredited centers (238 of 971 responded, 24.5%), weighted for nonresponse. Abstract read.
- 707Ghesquiere AR, Aldridge MD, Johnson-Hürzeler R, et al.
Hospice Services for Complicated Grief and Depression: Results from a National Survey. J Am Geriatr Soc 2015;63(10):2173-80. National survey of 591 US hospices conducted in 2008-2009; data are now dated. Abstract read.
- 708Rogers MM, Friebert S, Williams CSP, et al.
Pediatric Palliative Care Programs in US Hospitals. Pediatrics 2021;148(1). 2018 National Palliative Care Registry data from 54 inpatient pediatric programs; voluntary reporting by programs. Abstract read.
- 709Laird J, Cozad MJ, Keim-Malpass J, et al.
Variation In State Medicaid Implementation Of The ACA: The Case Of Concurrent Care For Children. Health Aff (Millwood) 2020;39(10):1770-1775. Review of state Medicaid guidelines implementing Affordable Care Act section 2302 concurrent care for children. Abstract read.
- 710Svynarenko R, Mack JW, Lindley LC
Differences in characteristics of children with cancer who receive standard versus concurrent hospice care. Pediatr Blood Cancer 2021;68(9):e29106. National Medicaid files on 1,685 children with cancer enrolled in hospice, 2011-2013. Abstract read.
- 330Harrison KL, Connor SR
First Medicare Demonstration of Concurrent Provision of Curative and Hospice Services for End-of-Life Care. Am J Public Health 2016;106(8):1405-8. Policy analysis describing US hospice origins in the 1970s, the Medicare hospice benefit rule that restricts eligibility to patients who no longer receive curative treatment, and the concurrent-care demonstration for people with six months or less to live; national policy scope; second author is affiliated with the Worldwide Hospice Palliative Care Alliance (advocacy organization). Abstract read.
- 332Stevenson DG, Dalton JB, Grabowski DC, et al.
Nearly half of all Medicare hospice enrollees received care from agencies owned by regional or national chains. Health Aff (Millwood) 2015;34(1):30-8. National analysis of Medicare cost reports 2000-11 showing growth of for-profit and multiagency chain ownership in the US hospice sector. Abstract read.
- 331Hargadon A, Tran Q, Stephen K, et al.
A Trial of Concurrent Care: Shedding Light on the Gray Zone. J Palliat Med 2017;20(2):207-210. Case report and framework paper stating US hospice eligibility criteria (estimated prognosis of 6 months and readiness to forgo disease-modifying treatment); single case, opinion-level evidence; one author affiliated with a for-profit hospice provider (Vitas Healthcare). Abstract read.
- 338Wang SE, Liu IA, Lee JS, et al.
End-of-Life Care in Patients Exposed to Home-Based Palliative Care vs Hospice Only. J Am Geriatr Soc 2019;67(6):1226-1233. Retrospective cohorts of decedents 65 and older in Kaiser Permanente Southern California (2011-2016) reporting median hospice length of stay of 12 to 13 days; single integrated health system; authors employed by the system that runs the program. Abstract read.
- 334Gozalo P, Plotzke M, Mor V, et al.
Changes in Medicare costs with the growth of hospice care in nursing homes. N Engl J Med 2015;372(19):1823-31. National Medicare analysis of 786,328 US nursing home decedents showing hospice election rose from 27.6% (2004) to 39.8% (2009) with a net increase in Medicare spending; nursing home population only; funded by CMS and NIA. Abstract read.
- 333Aldridge MD, Schlesinger M, Barry CL, et al.
National hospice survey results: for-profit status, community engagement, and service. JAMA Intern Med 2014;174(4):500-6. National random-sample survey of 591 Medicare-certified hospices (2008-2009) comparing for-profit and nonprofit hospices on charity care, Medicare aggregate cap, disenrollment and outreach. Abstract read.
- 335Melekis K, Weisse CS, Alonzo J, et al.
Social Model Hospice Residential Care Homes: Whom Do They Really Serve? Am J Hosp Palliat Care 2023;40(12):1317-1323. Chart review of 500 residents of three community-run residential care homes in Upstate New York; notes that the Medicare Hospice Benefit does not cover custodial care; regional scope. Abstract read.
- 337Oh A, Hunt LJ, Ritchie CS, et al.
Role of Home Health for Community-Dwelling Older Adults Near the End of Life: A Resource Beyond Hospice? J Palliat Med 2022;26(3):385-392. Nationally representative NHATS cohort of 1,057 US decedents (2012-2017) linked to Medicare claims showing shares using hospice only, home health only, both or neither in the last six months of life; older adults only. Abstract read.
- 336Jones CD, Moss A, Sevick C, et al.
Factors Associated With Mortality and Hospice Use Among Medicare Beneficiaries With Heart Failure Who Received Home Health Services. J Card Fail 2023;30(6):788-799. 100% national sample of Medicare fee-for-service beneficiaries with heart failure discharged to home health 2017-2018; 48.2% of decedents used hospice, with lower odds for Black, Hispanic, under-65 and Medicaid-eligible patients; heart failure subgroup only. Abstract read.
- 483Soltoff A, Purvis S, Ravicz M, et al.
Factors Influencing Palliative Care Access and Delivery for Great Plains American Indians. J Pain Symptom Manage 2022;64(3):276-286. Interviews with 38 specialty and Indian Health Service clinicians describe scarce hospice and home health on Great Plains reservations and reliance on extended family (tiospaye); clinician views only. Full text read.
- 484Daubman BR, Duran T, Johnson G, et al.
"Are They Just Experimenting With All of Us?" Cultural Considerations for Clinicians Caring for Seriously Ill Great Plains American Indians. Am J Hosp Palliat Care 2025;43(1):77-84. Talking circles and interviews with 36 cancer survivors, caregivers, Tribal leaders and traditional healers from 3 Great Plains reservations (community-based participatory research). Full text read.
- 487Johnson J, Hayden T, Taylor LA.
Evaluation of the LIGHT Curriculum: An African American Church-Based Curriculum for Training Lay Health Workers to Support Advance Care Planning, End-of-Life Decision Making, and Care. J Palliat Med 2021;25(3):413-420. Pre-post evaluation of 37 church-based lay health workers from 3 African American churches; evaluated by the curriculum developers. Abstract read.
- 486Siler S, Arora K, Doyon K, et al.
Spirituality and the Illness Experience: Perspectives of African American Older Adults. Am J Hosp Palliat Care 2021;38(6):618-625. Focus groups with 50 African American older adults and family caregivers recruited through 5 Denver-area churches. Abstract read.
- 485Quigley DD, McCleskey SG, Lesandrini J, et al.
Roles of Chaplains and Clergy in Spiritual Care for African Americans in Hospice: A Pilot Study. Am J Hosp Palliat Care 2024;42(8):717-727. Pilot qualitative study with 12 caregivers, 3 community clergy and 5 chaplains linked to one urban/suburban community hospice. Abstract read.
- 488Tobey M, Manasson J, Decarlo K, et al.
Homeless Individuals Approaching the End of Life: Symptoms and Attitudes. J Pain Symptom Manage 2016;53(4):738-744. Survey of 20 homeless people near the end of life at one medical respite home. Abstract read.