Survey: Adults dropped from Medicaid after pandemic faced healthcare access, affordability issues

Receiving big medical bill

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 A survey of low-income adults in four southern US states shows that nearly half of those disenrolled from Medicaid after COVID-19 pandemic protections ended had no insurance in late 2023, leading to struggles to afford healthcare and prescription drugs and threatening to broaden a gap that had narrowed during expanded governmental benefits.

The data were derived from 89,130 adult residents of Arkansas, Kentucky, Louisiana, and Texas participating in the National Health Interview Survey in 2019, 2021, and 2022. In 2023, states rechecked Medicaid eligibility after COVID-19 governmental protections expired, disenrolling millions. The average participant age was 48.0 years, and 51.6% were women.

Researchers from Beth Israel Medical Center and Harvard Medical School published the results late last week in JAMA Health Forum.

Poor adults less likely to forgo care amid COVID

Health insurance coverage rose among only low-income respondents during the pandemic (2022, 81.8%; 2019: 78.4%; adjusted relative risk [aRR], 1.04), while healthcare use decreased slightly in all income groups. 

Low-income adults were less likely to delay medical care during the pandemic than before because of cost (2022, 11.2%; 2019, 15.4%; aRR, 0.73). They were also less likely to forgo care (2022, 10.7%; 2019, 14.9%; aRR, 0.72). High-income adults, however, reported no changes in care-seeking, significantly narrowing income-based disparities.

Also during the pandemic, all respondents were less likely to struggle to pay medical bills, but their worry about paying the bills didn't change from before COVID-19. 

Similarly, low-income adults were less likely in 2022 than in 2019 to delay medications (9.4% vs 12.7%, respectively; aRR, 0.74), not fill prescriptions (8.9% vs 12.0%; aRR, 0.75), skip medications (6.7% vs 10.1%; aRR, 0.67), or take fewer medications (7.3% vs 11.2%; aRR, 0.65) due to costs. These patterns were similar among high-income respondents. 

Medicaid unwinding may move care out of reach

Improvements in measures of healthcare and prescription drug affordability persisted even after considering changes in insurance coverage and healthcare use. These patterns were similar when comparing measures of affordability in 2021 with those in 2019.

These findings suggest that the recent unwinding of COVID-19 pandemic–related safety-net policies may worsen health care affordability and widen existing income-based inequities.

"Despite initial increases in unemployment and economic loss, we found that medical care and prescription medications became more affordable for US adults during the COVID-19 pandemic," the study authors wrote. "Notably, this was a change from the prepandemic trend of health care affordability, which had been stable if not worsening."

They said the improvement in healthcare affordability for low-income respondents may be partially explained by the direct economic aid from stimulus checks, childcare credits, and expanded federal safety-net policies, such as those that offset income losses and doubled Supplemental Nutrition Assistance Program (SNAP) benefits from 2019 to 2022.

"Other considerations for the observed improvements in health care and prescription medication affordability, which our study was not able to account for, include US economic growth during the second half of the COVID-19 pandemic and/or changes in perceptions of the importance of medical care," they wrote.

The pandemic brought more affordable healthcare to low-income adults and lower prescription drug prices to income groups, the researchers concluded: "These findings suggest that the recent unwinding of COVID-19 pandemic–related safety-net policies may worsen health care affordability and widen existing income-based inequities."

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