COVID-19–Related Insurance Coverage Changes and Disparities in Access to Care Among Low-Income US Adults in 4 Southern States

Abstract

IMPORTANCE It is unclear how the COVID-19 pandemic and its associated economic downturn have affected insurance coverage and disparities in access to health care among low-income families and people of color in states that have and have not expanded Medicaid. OBJECTIVE To determine changes in insurance coverage and disparities in access to health care among low-income families and people of color across 4 Southern states and by Medicaid expansion status. DESIGN, SETTING, AND PARTICIPANTS This random-digit dialing telephone survey study of US citizens ages 19 to 64 years with a family income less than 138% of the federal poverty line in in 4 states (Arkansas, Kentucky, Louisiana, and Texas) was conducted from October to December 2020. Using a difference-in-differences design, we estimated changes in outcomes by Medicaid expansion status overall and by race and ethnicity in 2020 (n = 1804) compared with 2018 to 2019 (n = 5710). We also explored barriers to health care and use of telehealth by race and ethnicity. Data analysis was conducted from January 2021 to March 2021. EXPOSURES COVID-19 pandemic and prior Medicaid expansion status. MAIN OUTCOMES AND MEASURES Primary outcome was the uninsured rate and secondary outcomes were financial and nonfinancial barriers to health care access. RESULTS Of 7514 respondents (11% response rate; 3889 White non-Latinx [51.8%], 1881 Black non-Latinx [25.0%], and 1156 Latinx individuals [15.4%]; 4161 women [55.4%]), 5815 (77.4%) were in the states with previous expansion and 1699 (22.6%) were in Texas (nonexpansion state).Respondents in the expansion states were older, more likely White, and less likely to have attended college compared with respondents in Texas. Uninsurance rate in 2020 rose by 7.4 percentage points in Texas (95% CI, 2.2-12.6; P = .01) and 2.5 percentage points in expansion states (95% CI, −1.9 to 7.0; P = .27), with a difference-in-differences estimate for Medicaid expansion of −4.9% (95% CI, −11.3 to 1.6; P = .14). Among Black and Latinx individuals, Medicaid expansion was associated with protection against a rise in the uninsured rate (difference-in-differences, −9.5%; 95% CI, −19.0 to −0.1; P = .048). Measures of access, including having a personal physician and regular care for chronic conditions, worsened significantly in 2020 in all 4 states, with no significant difference by Medicaid expansion status. CONCLUSIONS AND RELEVANCEIn this survey of US adults, uninsured rates increased among low-income adults in 4 Southern states during the COVID-19 pandemic, but Medicaid expansion states, that association was diminished among Black and Latinx individuals. Nonfinancial barriers to care because of the pandemic were common in all states.

Comparison of Unemployment-Related Health Insurance Coverage Changes in Medicaid Expansion vs Nonexpansion States During the COVID-19 Pandemic

“…In addition, the results support those of previous studies 5 , 20 describing the use of broader eligibility guidelines for Medicaid to facilitate unemployment-related Medicaid enrollment during economic downturns (eg, the Great Recession from 2007 to 2009) and the increased accessibility to Medicaid among those affected by local economic downturns after passage of the ACA. In combination with other recent studies, 6 , 21 we believe that this study’s findings provide support for potentially stabilizing access to care through Medicaid expansion for households affected by job loss.…”

“… 5 Recent studies show that Medicaid enrollment during the COVID-19 crisis increased in states that expanded Medicaid. 6 , 7 However, the extent that increased Medicaid enrollments were predicated by job loss is unknown. 7 Whether Medicaid can function as a safety net depends largely on how easily workers can transition from private coverage to Medicaid after a job loss.…”

Changes in Employment Status and Access to Care During COVID-19 Pandemic Among Low-Income Adults in 4 Southern States

“…In prior work, Blacks and Latinos were more likely to be protected from loss of insurance during the pandemic if they lived in a state that expanded Medicaid. 12 Nationally, the number of people in Medicaid has increased, especially among the states that expanded Medicaid. 22 Currently, however, there are 12 states that have chosen not to expand Medicaid, resulting in about 2.2 million people who fall in this Medicaid coverage gap, of which the largest proportion (35%) reside in Texas.…”

“…We used the results of an ongoing survey of low-income adults residing in four Southern States: Arkansas, Kentucky, Louisiana, and Texas. 9 – 12 Three of the four states (all except Texas) have expanded their Medicaid program under the Affordable Care Act. The survey we report on here was conducted between October 5, 2020, and December 23, 2020, by the vendor, Social Science Research Solutions (SSRS).…”

Racial and Ethnic Disparities in Insurance Coverage Among US Adults Aged 60 to 64 Years

“…Emerging evidence suggests coverage disparities during the pandemic widened in nonexpansion states. 6 Thus, our results may conservatively reflect the current extent of coverage disparities among older adults.…”