Changes in Health Care Access by Race, Income, and Medicaid Expansion During the COVID-19 Pandemic

Background:The intersecting crises of the COVID-19 pandemic, job losses, and concomitant loss of employer-sponsored health insurance may have disproportionately affected health care access within minorized and lower-socioeconomic status communities. Objective:To describe changes in access to care during the COVID-19 pandemic, stratified by race/ethnicity, household income, and state Medicaid expansion status. Research Design:We used interrupted time series and difference-in-differences regression models, controlling for respondent characteristics and preexisting trends. Subjects:Data were extracted for all adults aged 18-64 surveyed in the 2015-2020 Behavioral Risk Factor Surveillance System (N=1,731,699) from all 50 states and the District of Columbia. Measures:Our outcomes included indicators for whether respondents had any health insurance coverage or avoided seeking care because of cost within the prior year. The primary exposure was the onset of the COVID-19 pandemic in the United States in March 2020. Results:The pandemic was associated with a 1.2 percentage point (pp) decline in uninsurance for Medicaid expansion states (95% CI, -1.8, -0.6); these reductions were concentrated among respondents who were Black, multiracial, or low income. The rates of uninsurance were generally stable in nonexpansion states. The rates of avoided care because of cost fell by 3.5 pp in Medicaid expansion states (95% CI, -3.9, -3.1), and by 3.6 pp (95% CI, 4.3-2.9) in nonexpansion states. These declines were concentrated among respondents who were Hispanic, Other Race, or low income. Conclusions:Our findings reinforce the value of Medicaid expansion as one tool to improve access to health insurance and care for marginalized and vulnerable populations.