Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts.
JAMA Health Forum. 2021 Aug 13;2(8):e212007. doi: 10.1001/jamahealthforum.2021.2007. eCollection 2021 Aug.
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.
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.
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.
COVID-19 pandemic and prior Medicaid expansion status.
Primary outcome was the uninsured rate and secondary outcomes were financial and nonfinancial barriers to health care access.
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; = .01) and 2.5 percentage points in expansion states (95% CI, -1.9 to 7.0; = .27), with a difference-in-differences estimate for Medicaid expansion of -4.9% (95% CI, -11.3 to 1.6; = .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; = .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.
In 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.
重要性：尚不清楚在已经扩大医疗补助范围和尚未扩大医疗补助范围的州，新冠疫情及其相关经济衰退如何影响低收入家庭和少数族裔人群的保险覆盖范围和获得医疗保健的机会。
目的：确定在 4 个南方州和按医疗补助扩展情况，对收入较低的家庭和少数族裔人群的保险覆盖范围和获得医疗保健机会的变化。
设计：这是一项在 2020 年 10 月至 12 月期间，对美国 4 个州（阿肯色州、肯塔基州、路易斯安那州和德克萨斯州）年龄在 19 岁至 64 岁之间、家庭收入低于联邦贫困线 138%的公民进行的随机拨号电话调查研究。采用双重差分设计，我们比较了 2020 年（n=1804）和 2018 年至 2019 年（n=5710）按医疗补助扩展情况和种族和民族的结果变化。我们还探讨了种族和民族在获得医疗保健和使用远程医疗方面的障碍。数据分析于 2021 年 1 月至 2021 年 3 月进行。
暴露因素：新冠疫情和先前的医疗补助扩展情况。
主要结果和措施：主要结果是未参保率，次要结果是获得医疗保健的财务和非财务障碍。
结果：在 7514 名受访者中（11%的回应率；3889 名白人非拉丁裔[51.8%]、1881 名黑人非拉丁裔[25.0%]和 1156 名拉丁裔[15.4%]；4161 名女性[55.4%]），5815 名（77.4%）在先前有扩展的州，1699 名（22.6%）在德克萨斯州（无扩展）。与德克萨斯州的受访者相比，扩展州的受访者年龄较大，更可能是白人，上大学的可能性较小。2020 年，德克萨斯州的未参保率上升了 7.4 个百分点（95%CI，2.2-12.6； = .01），扩展州上升了 2.5 个百分点（95%CI，-1.9 至 7.0； = .27），医疗补助扩展的差异估计值为-4.9%（95%CI，-11.3 至 1.6； = .14）。在黑人和拉丁裔人群中，医疗补助的扩大与未参保率上升的保护作用相关（差异估计值，-9.5%；95%CI，-19.0 至-0.1； = .048）。在所有 4 个州，2020 年获得医疗保健的措施（包括有私人医生和定期接受慢性病护理）都显著恶化，而医疗补助扩展状况没有显著差异。
结论：在这项对美国成年人的调查中，在新冠疫情期间，4 个南部州的低收入成年人的未参保率上升，但在黑人和拉丁裔人群中，医疗补助扩展州的这一关联有所减弱。由于疫情，所有州的医疗保健非财务障碍都很常见。
