Employer-Sponsored Coverage Stabilized And Uninsurance Declined In The Second Year Of The COVID-19 Pandemic.

The health risks of COVID-19, combined with widespread economic instability in the US, spurred Congress to pass temporary measures to improve access to health insurance. Using data from the Household Pulse Survey, a high-frequency, population-based survey, we examined trends in health coverage during 2021 and early 2022 among nonelderly adults. We estimated that eight million people gained coverage during this period, primarily because of increases in Medicaid and other public coverage. Despite rising employment, rates of employer-sponsored coverage remained flat. In Medicaid expansion states, employment rates increased significantly among Medicaid enrollees. Our results suggest that when the public health emergency ends, many people currently enrolled in Medicaid might no longer be eligible, particularly in Medicaid expansion states. Policy makers and employers should be prepared to help people who lose Medicaid eligibility identify and navigate enrollment in alternative sources of health insurance, including both Affordable Care Act Marketplace and employer-sponsored coverage.

Effects of social distancing policy on labor market outcomes

US workers receive unemployment benefits if they lose their job, but not for reduced working hours. In alignment with the benefits incentives, we find that the labor market responded to COVID-19 and related closure-policies mostly on the extensive (12 pp outright job loss) margin. Exploiting timing variation in state closure-policies, difference-in-differences (DiD) estimates show, between March 12 and April 12, 2020, employment rate fell by 1.7 pp for every 10 extra days of state stay-at-home orders (SAH), with little effect on hours worked/earnings among those employed. Forty percentage of the unemployment was due to a nationwide shock, rest due to social-distancing policies, particularly among "non-essential" workers.

Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic.

Importance: COVID-19 disrupted delivery of buprenorphine and naltrexone treatment for opioid use disorder (OUD), and during the pandemic, members of racial and ethnic minority groups experienced increased COVID-19 and opioid overdose risks compared with White individuals. However, whether filled buprenorphine and naltrexone prescriptions varied across racial and ethnic groups during the COVID-19 pandemic remains unknown. Objective: To investigate whether disruptions in filled buprenorphine and naltrexone prescriptions differed by race and ethnicity and insurance status or payer type. Design, Setting, and Participants: This cross-sectional study used retail pharmacy claims from May 2019 to June 2021 from the Symphony Health database, which includes 92% of US retail pharmacy claims, with race and ethnicity data spanning all insurance status and payer categories. Interrupted time series were used to estimate levels and trends of dispensed buprenorphine and naltrexone prescriptions before and after pandemic onset. Included individuals were those who filled buprenorphine and extended-release naltrexone prescriptions. Data were analyzed from July 2021 through March 2022. Main Outcomes and Measures: Weekly rates of dispensed buprenorphine and extended-release naltrexone prescription fills per 1000 patients and proportion of longer (ie, ≥14 days' supply) buprenorphine prescription fills were calculated. Analyses were stratified by patient race and ethnicity and further by insurance status and payer type for White and Black patients. Results: A total of 1 556 860 individuals who filled buprenorphine prescriptions (4359 Asian [0.3%], 94 657 Black [6.1%], 55 369 Hispanic [3.6%], and 664 779 White [42.7%]) and 127 506 individuals who filled extended-release naltrexone prescriptions (344 Asian [0.3%], 8186 Black [6.4%], 5343 Hispanic [4.2%], and 53 068 White [41.6%]) from May 6, 2019, to June 5, 2021, were analyzed. Prepandemic increases in buprenorphine fill rate flattened for all groups after COVID-19 onset (30.5 percentage point difference in trend; P < .001) compared with prepandemic trends. Significant level decreases in buprenorphine fills (ranging from 2.5% for Black patients; P = .009 to 4.0% for Hispanic patients; P = .009) at pandemic onset were observed for members of racial and ethnic minority groups but not White patients. At pandemic onset, rate of buprenorphine fills decreased in level for Medicare and cash-paying patients but with greater decreases for Black patients (Medicare: 10.0%; P < .001; cash: 20.0%; P < .001) than White patients (Medicare: 3.5%; P = .004; cash: 15.0%; P < .001). No decreases were found among Medicaid patients. Unlike buprenorphine, extended-release naltrexone had uniform level (from 10.0% for White patients with private insurance; P < .001 to 23.3% for Black patients with Medicare; P < .001) and trend (from 15.5 percentage points for White patients with Medicaid; P = .001 to 52.0 percentage points for Black patients with private insurance; P < .001) decreases across groups. Conclusions and Relevance: This study found that the COVID-19 pandemic was associated with immediate decreases in filled buprenorphine prescriptions by members of racial and ethnic minority groups but not White individuals. These findings suggest that members of racial and ethnic minority groups had larger losses in buprenorphine access during the pandemic across payer types.

US Trends in COVID-19–Associated Hospitalization and Mortality Rates Before and After Reopening Economies

Key Points Question Did the trends in COVID-19–related hospitalizations and deaths change after states reopened their economies? Findings In this cross-sectional study of COVID-19–related hospitalizations and deaths across 47 US states between April 16 and July 31, 2020, the daily trend of hospitalizations after state reopenings was higher by 1.607 per 100 000 population. The change in the mortality rate trend was not significant. Meaning These findings suggest that data on COVID-19–related hospitalizations and mortality trends can be used to guide health policy as states make decisions to open or close activities in response to this and future pandemics. Importance After abrupt closures of businesses and public gatherings in the US in late spring 2020 due to the COVID-19 pandemic, by mid-May 2020, most states reopened their economies. Owing in part to a lack of earlier data, there was little evidence on whether state reopening policies influenced important pandemic outcomes—COVID-19–related hospitalizations and mortality—to guide future decision-making in the remainder of this and future pandemics. Objective To investigate changes in COVID-19–related hospitalizations and mortality trends after reopening of US state economies. Design, Setting, and Participants Using an interrupted time series approach, this cross-sectional study examined trends in per-capita COVID-19–related hospitalizations and deaths before and after state reopenings between April 16 and July 31, 2020. Daily state-level data from the University of Minnesota COVID-19 Hospitalization Tracking Project on COVID-19–related hospitalizations and deaths across 47 states were used in the analysis. Exposures Dates that states reopened their economies. Main Outcomes and Measures State-day observations of COVID-19–related hospitalizations and COVID-19–related new deaths per 100 000 people. Results The study included 3686 state-day observations of hospitalizations and 3945 state-day observations of deaths. On the day of reopening, the mean number of hospitalizations per 100 000 people was 17.69 (95% CI, 12.54-22.84) and the mean number of daily new deaths per 100 000 people was 0.395 (95% CI, 0.255-0.536). Both outcomes displayed flat trends before reopening, but they started trending upward thereafter. Relative to the hospitalizations trend in the period before state reopenings, the postperiod trend was higher by 1.607 per 100 000 people (95% CI, 0.203-3.011;P = .03). This estimate implied that nationwide reopenings were associated with 5319 additional people hospitalized for COVID-19 each day. The trend in new deaths after reopening was also positive (0.0376 per 100 000 people;95% CI, 0.0038-0.0715;P = .03), but the change in mortality trend was not significant (0.0443;95% CI, −0.0048 to 0.0933;P = .08). Conclusions and Relevance In this cross-sectional study conducted over a 3.5-month period across 47 US states, data on the association of hospitalizations and mortality with state reopening policies may provide input to state projections of the pandemic as policy makers continue to balance public health protections with sustaining economic activity. This cross-sectional study evaluates trends in hospitalization and death rates related to COVID-19 in US states between closures and reopenings of businesses and public gatherings in 2020.

Trends in US Health Insurance Coverage During the COVID-19 Pandemic

This cross-sectional study seeks to determine how health insurance coverage changed in the US during the COVID-19 pandemic. Key Points Question How did health insurance coverage change during the COVID-19 pandemic? Findings In this cross-sectional survey study of more than 1.2 million US adults, rates of employer-sponsored coverage declined and rates of other types of coverage increased after the pandemic began and throughout 2020. Rates of uninsurance increased, particularly during the spring and summer. Meaning While public programs played an important role in protecting US adults from pandemic-driven declines in employer-sponsored coverage, many people became uninsured during the pandemic. Importance While most working-age adults in the US obtain health insurance through an employer, little is known about the implications of the massive pandemic-related job loss in March 2020 and subsequent rebound for rates of employer-sponsored coverage and uninsurance. Objective To determine how health insurance coverage changed during the COVID-19 pandemic. Design, Setting, and Participants Analysis of trends in insurance coverage based on repeated cross sections of the US Census Bureau’s Household Pulse Survey data, using linear regression to adjust for respondent’s demographic and socioeconomic characteristics and state of residence. More than 1.2 million US adults aged 18 to 64 years were surveyed from April 23 through December 21, 2020. Exposures The COVID-19 pandemic, separated into spring and summer and fall and winter time periods during 2020, as well as state Medicaid expansion status. Main Outcomes and Measures Regression-based estimates of the weekly percentage-point change in respondents’ health insurance status, including having any health insurance, any employer-sponsored health insurance, or only nonemployer sponsored coverage. Nonemployer-sponsored coverage is categorized into private, Medicaid, and other public in some analyses. Results The study population included 1 212 816 US adults (51% female;mean [SD] age, 42 [13] years) across all 50 US states and Washington DC. Among these respondents, rates of employer-sponsored coverage declined by 0.2 percentage points each week during the COVID-19 pandemic. Other types of coverage, particularly from public sources, increased by 0.1 and 0.2 percentage points in the spring and summer and fall and winter periods, respectively. Overall, health insurance coverage of any type declined, particularly during the spring and summer period, during which uninsurance increased by 1.4 percentage points, representing more than 2.7 million newly uninsured people, over a 12-week period. Conclusions and Relevance In this cross-sectional study of data from the US Census Bureau’s Household Pulse Survey, results showed that while public programs played an important role in protecting US adults from pandemic-driven declines in employment-sponsored coverage, many people became uninsured during 2020.

Substitution of Nonpharmacologic Therapy With Opioid Prescribing for Pain During the COVID-19 Pandemic.

Importance: During the pandemic, access to medical care unrelated to COVID-19 was limited because of concerns about viral spread and corresponding policies. It is critical to assess how these conditions affected modes of pain treatment, given the addiction risks of prescription opioids. Objective: To assess the trends in opioid prescription and nonpharmacologic therapy (ie, physical therapy and complementary medicine) for pain management during the COVID-19 pandemic in 2020 compared with the patterns in 2019. Design, Setting, and Participants: This retrospective, cross-sectional study used weekly claims data from 24 million US patients in a nationwide commercial insurance database (Optum's deidentified Clinformatics Data Mart Database) from January 1, 2019, to September 31, 2020. Among patients with diagnoses of limb, extremity, or joint pain, back pain, and neck pain for each week, patterns of treatment use were identified and evaluated. Data analysis was performed from April 1, 2021, to September 31, 2021. Main Outcomes and Measures: The main outcomes of interest were weekly rates of opioid prescriptions, the strength and duration of related opioid prescriptions, and the use of nonpharmacologic therapy. Transition rates between different treatment options before the outbreak and during the early months of the pandemic were also assessed. Results: A total of 21 430 339 patients (mean [SD] age, 48.6 [24.0] years; 10 960 507 [51.1%] female; 909 061 [4.2%] Asian, 1 688 690 [7.9%] Black, 2 276 075 [10.6%] Hispanic, 11 192 789 [52.2%] White, and 5 363 724 [25.0%] unknown) were enrolled during the first 3 quarters in 2019 and 20 759 788 (mean [SD] age, 47.0 [23.8] years; 10 695 690 [51.5%] female; 798 037 [3.8%] Asian; 1 508 023 [7.3%] Black, 1 976 248 [9.5%] Hispanic, 10 059 597 [48.5%] White, and 6 417 883 [30.9%] unknown) in the first 3 quarters of 2020. During the COVID-19 pandemic, the proportion of patients receiving a pain diagnosis was smaller than that for the same period in 2019 (mean difference, -15.9%; 95% CI, -16.1% to -15.8%). Patients with pain were more likely to receive opioids (mean difference, 3.5%; 95% CI, 3.3%-3.7%) and less likely to receive nonpharmacologic therapy (mean difference, -6.0%; 95% CI, -6.3% to -5.8%), and opioid prescriptions were longer and more potent during the early pandemic in 2020 relative to 2019 (mean difference, 1.07 days; 95% CI, 1.02-1.17 days; mean difference, 0.96 morphine milligram equivalents; 95% CI, 0.76-1.20). Analysis of individuals' transitions between treatment options for pain found that patients were more likely to transition out of nonpharmacologic therapy, replacing it with opioid prescriptions for pain management during the COVID-19 pandemic than in the year before. Conclusions and Relevance: Nonpharmacologic therapy is a benign treatment for pain often recommended instead of opioid therapy. The decrease in nonpharmacologic therapy and increase in opioid prescription during the COVID-19 pandemic found in this cross-sectional study, especially given longer days of prescription and more potent doses, may exacerbate the US opioid epidemic. These findings suggest that it is imperative to investigate the implications of limited medical access on treatment substitution, which may increase patient risk, and implement policies and guidelines to prevent those substitutions.

Tracking Public and Private Responses to the COVID-19 Epidemic: Evidence from State and Local Government Actions

This paper examines the determinants of social distancing during the COVID-19 epidemic. We classify state and local government actions, and we study multiple proxies for social distancing based on data from smart devices. Mobility fell substantially in all states, even ones that have not adopted major distancing mandates. There is little evidence, for example, that stay-at-home mandates induced distancing. In contrast, early and information-focused actions have had bigger effects. Event studies show that first case announcements, emergency declarations, and school closures reduced mobility by 1-5% after 5 days and 7-45% after 20 days. Between March 1 and April 11, average time spent at home grew from 9.1 hours to 13.9 hours. We find, for example, that without state emergency declarations, event study estimates imply that hours at home would have been 11.3 hours in April, suggesting that 55% of the growth comes from emergency declarations and 45% comes from secular (non-policy) trends. State and local government actions induced changes in mobility on top of a large response across all states to the prevailing knowledge of public health risks. Early state policies conveyed information about the epidemic, suggesting that even the policy response mainly operates through a voluntary channel.

Mandated and Voluntary Social Distancing During The COVID-19 Epidemic: A Review

For much of 2020, the COVID-19 epidemic upended social and economic life globally. In an effort to reduce COVID-19 risks in the U.S., state and local governments issued many recommendations and regulations to induce social distancing, adding to voluntary reductions in interpersonal contact. The responses to the epidemic helped contain spread, but also lead to high unintended societal costs. In the summer months, states took steps to revive the economy and lift social distancing regulations. However, as many epidemiologists expected, the scale of the epidemic has expanded very rapidly in the fall. In the week of October 14, the US generated around 57,000 new COVID-19 cases and 700 deaths each day. By November 15, the country was generating about 151,000 new cases and 1,200 deaths per day. These rapid increases in cases and deaths raise concerns about the capacity of local healthcare systems around the country. State governments are once again facing difficult choices about whether and how to use policies to address the spread of the virus. The incoming Biden-Harris administration faces an important challenge in trying to manage the epidemic as well as a large scale vaccination campaign. Although the epidemic is less than a year old, it has generated a huge volume of research by economists, epidemiologists, and others. This body of work may help inform policy decisions facing society in the coming months. In this paper, we make five broad contributions. First, we provide a concise review of economic and social science research on mobility patterns, labor market outcomes, consumer behavior, and population health during the first phase of the epidemic. Second, we sketch a simple microeconomic model that may be useful considering the determinants of social distancing and the role of different policy instruments in promoting distancing. Third, we present a simple typology of the policies that were used at the state and county levels during the closure and re-opening phases of the epidemic in the U.S.. Fourth, we review a collection of new data sources that have played an important role in monitoring and analyzing population behavior this year. Fifth, we present results from event study regressions that try to disentangle private vs. policy-induced changes in mobility patterns during the early part of the epidemic.

Impacts of State Reopening Policy on Human Mobility

This study quantifies the effect of state reopening policies on daily mobility, travel, and mixing behavior during the COVID-19 pandemic. We harness cell device signal data to examine the effects of the timing and pace of reopening plans in different states. We quantify the increase in mobility patterns during the reopening phase by a broad range of cell-device-based metrics. Soon (four days) after reopening, we observe a 6% to 8% mobility increase. In addition, we find that temperature and precipitation are strongly associated with increased mobility across counties. The mobility measures that reflect visits to a greater variety of locations responds the most to reopening policies, while total time in vs. outside the house remains unchanged. The largest increases in mobility occur in states that were late adopters of closure measures, suggesting that closure policies may have represented more of a binding constraint in those states. Together, these four observations provide an assessment of the extent to which people in the U.S. are resuming movement and physical proximity as the COVID-19 pandemic continues.

Effects of Social Distancing Policy on Labor Market Outcomes

This paper examines the impact of the social distancing policies states adopted between March and April of 2020 in response to the COVID-19 epidemic. These actions, together with voluntary social distancing, appear to have reduced the rate of new COVID-19 cases and deaths, but raised concerns about the costs experienced by workers and businesses. Estimates from difference-in-difference models that leverage cross-state variation in the timing of business closures and stay-at-home mandates suggest that the employment rate fell by about 1.7 percentage points for every extra 10 days that a state experienced a stay-at-home mandate during the period March 12-April 12, 2020;select business closure laws were associated with similar employment effects. Our estimates imply that about 40% of the 12 percentage point decline in employment rates between January and April 2020 was due to a nationwide shock while about 60% was driven by state social distancing policies. The negative employment effects of state policies were larger for workers in "non-essential" industries, workers without a college degree, and early-career workers. Policy caused relatively modest changes in hours worked and earnings among those who remain employed. We find no concerning evidence of pre-trends in the monthly (low-frequency) CPS data, but use high-frequency data on work-related mobility measured from cellphones, job-loss-related internet searches, and initial unemployment claims to investigate the possibility that the large employment effects experienced in April could have occurred after the March CPS but but before policy adoption. In those analyses, we find pre-trends for some outcomes but not others. Thus we cannot fully rule out that some employment effects shortly predated the policies. As states relax business closures, ensuring gains in labor market activities in ways that continue to mitigate COVID-19 "surges" and public health risks will be key considerations to monitor.

Back to Business and (Re)employing Workers? Labor Market Activity During State COVID-19 Reopenings

In the early phases of the COVID-19 epidemic labor markets exhibited considerable churn, which we relate to three primary findings. First, reopening policies generated asymmetrically large increases in reemployment of those out of work, compared to modest decreases in job loss among those employed. Second, most people who were reemployed appear to have returned to their previous employers, but the rate of reemployment decreases with time since job loss. Lastly, the groups that had the highest unemployment rates in April also tended to have the lowest reemployment rates, potentially making churn harmful to people and groups with more and/or longer job losses. Taken together, these estimates suggest that employment relationships are durable in the short run, but raise concerns that employment gains requiring new employment matches may not be as rapid and may be particularly slow for hard-hit groups including Hispanic and Black workers, youngest and oldest workers, and women.

US Trends in COVID-19-Associated Hospitalization and Mortality Rates Before and After Reopening Economies.

Importance: After abrupt closures of businesses and public gatherings in the US in late spring 2020 due to the COVID-19 pandemic, by mid-May 2020, most states reopened their economies. Owing in part to a lack of earlier data, there was little evidence on whether state reopening policies influenced important pandemic outcomes-COVID-19-related hospitalizations and mortality-to guide future decision-making in the remainder of this and future pandemics. Objective: To investigate changes in COVID-19-related hospitalizations and mortality trends after reopening of US state economies. Design Setting and Participants: Using an interrupted time series approach, this cross-sectional study examined trends in per-capita COVID-19-related hospitalizations and deaths before and after state reopenings between April 16 and July 31, 2020. Daily state-level data from the University of Minnesota COVID-19 Hospitalization Tracking Project on COVID-19-related hospitalizations and deaths across 47 states were used in the analysis. Exposures: Dates that states reopened their economies. Main Outcomes and Measures: State-day observations of COVID-19-related hospitalizations and COVID-19-related new deaths per 100 000 people. Results: The study included 3686 state-day observations of hospitalizations and 3945 state-day observations of deaths. On the day of reopening, the mean number of hospitalizations per 100 000 people was 17.69 (95% CI, 12.54-22.84) and the mean number of daily new deaths per 100 000 people was 0.395 (95% CI, 0.255-0.536). Both outcomes displayed flat trends before reopening, but they started trending upward thereafter. Relative to the hospitalizations trend in the period before state reopenings, the postperiod trend was higher by 1.607 per 100 000 people (95% CI, 0.203-3.011; P = .03). This estimate implied that nationwide reopenings were associated with 5319 additional people hospitalized for COVID-19 each day. The trend in new deaths after reopening was also positive (0.0376 per 100 000 people; 95% CI, 0.0038-0.0715; P = .03), but the change in mortality trend was not significant (0.0443; 95% CI, -0.0048 to 0.0933; P = .08). Conclusions and Relevance: In this cross-sectional study conducted over a 3.5-month period across 47 US states, data on the association of hospitalizations and mortality with state reopening policies may provide input to state projections of the pandemic as policy makers continue to balance public health protections with sustaining economic activity.

Impacts of state COVID-19 reopening policy on human mobility and mixing behavior.

This study quantifies the effect of the 2020 state COVID economic activity reopening policies on daily mobility and mixing behavior, adding to the economic literature on individual responses to public health policy that addresses public contagion risks. We harness cellular device signal data and the timing of reopening plans to provide an assessment of the extent to which human mobility and physical proximity in the United States respond to the reversal of state closure policies. We observe substantial increases in mixing activities, 13.56% at 4 days and 48.65% at 4 weeks, following reopening events. Echoing a theme from the literature on the 2020 closures, mobility outside the home increased on average prior to these state actions. Furthermore, the largest increases in mobility occurred in states that were early adopters of closure measures and hard-hit by the pandemic, suggesting that psychological fatigue is an important barrier to implementation of closure policies extending for prolonged periods of time.

Trends in US Health Insurance Coverage During the COVID-19 Pandemic.

Importance: While most working-age adults in the US obtain health insurance through an employer, little is known about the implications of the massive pandemic-related job loss in March 2020 and subsequent rebound for rates of employer-sponsored coverage and uninsurance. Objective: To determine how health insurance coverage changed during the COVID-19 pandemic. Design Setting and Participants: Analysis of trends in insurance coverage based on repeated cross sections of the US Census Bureau's Household Pulse Survey data, using linear regression to adjust for respondent's demographic and socioeconomic characteristics and state of residence. More than 1.2 million US adults aged 18 to 64 years were surveyed from April 23 through December 21, 2020. Exposures: The COVID-19 pandemic, separated into spring and summer and fall and winter time periods during 2020, as well as state Medicaid expansion status. Main Outcomes and Measures: Regression-based estimates of the weekly percentage-point change in respondents' health insurance status, including having any health insurance, any employer-sponsored health insurance, or only nonemployer sponsored coverage. Nonemployer-sponsored coverage is categorized into private, Medicaid, and other public in some analyses. Results: The study population included 1 212 816 US adults (51% female; mean [SD] age, 42 [13] years) across all 50 US states and Washington DC. Among these respondents, rates of employer-sponsored coverage declined by 0.2 percentage points each week during the COVID-19 pandemic. Other types of coverage, particularly from public sources, increased by 0.1 and 0.2 percentage points in the spring and summer and fall and winter periods, respectively. Overall, health insurance coverage of any type declined, particularly during the spring and summer period, during which uninsurance increased by 1.4 percentage points, representing more than 2.7 million newly uninsured people, over a 12-week period. Conclusions and Relevance: In this cross-sectional study of data from the US Census Bureau's Household Pulse Survey, results showed that while public programs played an important role in protecting US adults from pandemic-driven declines in employment-sponsored coverage, many people became uninsured during 2020.

Vaccinations Against COVID-19 May Have Averted Up To 140,000 Deaths In The United States.

COVID-19 vaccination campaigns continue in the United States, with the expectation that vaccines will slow transmission of the virus, save lives, and enable a return to normal life in due course. However, the extent to which faster vaccine administration has affected COVID-19-related deaths is unknown. We assessed the association between US state-level vaccination rates and COVID-19 deaths during the first five months of vaccine availability. We estimated that by May 9, 2021, the US vaccination campaign was associated with a reduction of 139,393 COVID-19 deaths. The association varied in different states. In New York, for example, vaccinations led to an estimated 11.7 fewer COVID-19 deaths per 10,000, whereas Hawaii observed the smallest reduction, with an estimated 1.1 fewer deaths per 10,000. Overall, our analysis suggests that the early COVID-19 vaccination campaign was associated with reductions in COVID-19 deaths. As of May 9, 2021, reductions in COVID-19 deaths associated with vaccines had translated to value of statistical life benefit ranging between $625 billion and $1.4 trillion.