Health Insurance and Access to Care After Unemployment in Medicaid Expansion Versus Nonexpansion States During COVID-19

BACKGROUND: Prior work has shown that Medicaid coverage offset reductions in employer-sponsored insurance after COVID-19-related job loss in Medicaid expansion states. However, the effect of Medicaid expansion on health care access is not fully understood. OBJECTIVE: To estimate the association of unemployment during COVID-19 with health insurance coverage and health care access in Medicaid expansion versus nonexpansion states. STUDY DESIGN: We used restricted, longitudinal National Health Interview Survey (NHIS) data from 2019 to 2020, focusing on working-age adults (N=5156). Using triple-difference models, we estimated changes in outcomes for respondents becoming unemployed between 2019 and 2020 (after COVID-19) relative to continuously employed respondents, in Medicaid expansion versus nonexpansion states. PRINCIPAL FINDINGS: Compared with continuously employed respondents, there was a statistically significant increase in Medicaid coverage among the newly unemployed in expansion states (6.1 percentage points (pp), 95% CI: 1.0 to 11.3, P=0.019) but not in nonexpansion states (3.9 pp, 95% CI: -3.9 to 11.8, P=0.324); however, the triple difference was nonsignificant. Uninsurance increased among the newly unemployed in expansion states by only 4.9 pp (95% CI: 0.9 to 8.9, P=0.016) versus 12.4 pp in nonexpansion states (95% CI: 0.2 to 24.6, P=0.047), but the triple difference was statistically nonsignificant. There was a significant increase in delaying or skipping medical care among newly unemployed respondents in nonexpansion states, but not in expansion states and the triple difference was statistically significant (-15.5 pp, 95% CI: -26.9 to -4.0, P=0.008). CONCLUSION: Our results suggest that Medicaid expansion prevented disruptions in health care access for the newly unemployed during COVID-19.