Changes in Health Care and Prescription Medication Affordability in the US During the COVID-19 Pandemic.

Importance: In the US, the COVID-19 pandemic led to a significant rise in unemployment and economic loss that disproportionately impacted low-income individuals. It is unknown how health care and prescription medication affordability changed among low-income adults during the COVID-19 pandemic overall and compared with their higher-income counterparts. Objective: To evaluate changes in health care affordability and prescription medication affordability during the COVID-19 pandemic (2021 and 2022) compared with pre-COVID-19 pandemic levels (2019) and whether income-based inequities changed. Design, Setting, and Participants: This retrospective cross-sectional study included adults 18 years and older participating in the National Health Interview Survey (NHIS) in 2019, 2021, and 2022. Low-income adults were defined as having a household income of 200% or less of the federal poverty level (FPL); middle-income adults, 201% to 400% of the FPL; and high-income adults, more than 400% of the FPL. Data were analyzed from June to November 2023. Main Outcomes and Measures: Measures of health care affordability and prescription medication affordability. Results: The study population included 89 130 US adults. Among the weighted population, 51.6% (95% CI, 51.2-52.0) were female, and the mean (SD) age was 48.0 (0.12) years. Compared with prepandemic levels, during the COVID-19 pandemic, low-income adults were less likely to delay medical care (2022: 11.2%; 95% CI, 10.3-12.1; 2019: 15.4%; 95% CI, 14.3-16.4; adjusted relative risk [aRR], 0.73; 95% CI, 0.66-0.81) or avoid care (2022: 10.7%; 95% CI, 9.7-11.6; 2019: 14.9%; 95% CI, 13.8-15.9; aRR, 0.72; 95% CI, 0.64-0.80) due to cost, while high-income adults experienced no change, resulting in a significant improvement in income-based disparities. Low-income and high-income adults were less likely to experience problems paying medical bills but experienced no change in worrying about medical bills during the COVID-19 pandemic compared with prepandemic levels. Across measures of prescription medication affordability, low-income adults were less likely to delay medications (2022: 9.4%; 95% CI, 8.4-10.4; 2019: 12.7%; 95% CI, 11.6-13.9; aRR, 0.74; 95% CI, 0.65-0.84), not fill medications (2022: 8.9%; 95% CI, 8.1-9.8; 2019: 12.0%; 95% CI, 11.1-12.9; aRR, 0.75; 95% CI, 0.66-0.83), skip medications (2022: 6.7%; 95% CI, 5.9-7.6; 2019: 10.1%; 95% CI, 9.1-11.1; aRR, 0.67; 95% CI, 0.57-0.77), or take less medications (2022: 7.3%; 95% CI, 6.4-8.1; 2019: 11.2%; 95% CI, 10.%-12.2; aRR, 0.65; 95% CI, 0.56-0.74) due to costs, and these patterns were largely similar among high-income adults. Improvements in measures of health care and prescription medication affordability persisted even after accounting for changes in health insurance coverage and health care use. These patterns were similar when comparing measures of affordability in 2021 with 2019. Conclusions and Relevance: Health care affordability improved for low-income adults during the COVID-19 pandemic, resulting in a narrowing of income-based disparities, while prescription medication affordability improved for all income groups. 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.

Health Care Access and Cardiovascular Risk Factor Management Among Working-Age US Adults During the Pandemic.

BACKGROUND: Low-income working-age US adults disproportionately experienced health care disruptions at the onset of the coronavirus disease 2019 pandemic. Little is known about how health care access and cardiovascular risk factor management changed as the pandemic went on or if patterns differed by state Medicaid expansion status. METHODS: Cross-sectional data from the behavioral risk factor surveillance system were used to compare self-reported measures of health care access and cardiovascular risk factor management among US adults aged 18 to 64 years in 2021 (pandemic) to 2019 (prepandemic) using multivariable Poisson regression models. We assessed differential changes between low-income (<138% federal poverty level) and high-income (>400% federal poverty level) working-age adults by including an interaction term for income group and year. We then evaluated changes among low-income adults in Medicaid expansion versus nonexpansion states using a similar approach. RESULTS: The unweighted study population included 80 767 low-income and 184 136 high-income adults. Low-income adults experienced improvements in insurance coverage (relative risk [RR], 1.10 [95% CI, 1.08-1.12]), access to a provider (RR, 1.12 [95% CI, 1.09-1.14]), and ability to afford care (RR, 1.07 [95% CI, 1.05-1.09]) in 2021 compared with 2019. While these measures also improved for high-income adults, gains in coverage and ability to afford care were more pronounced among low-income adults. However, routine visits (RR, 0.96 [95% CI, 0.94-0.98]) and cholesterol testing (RR, 0.93 [95% CI, 0.91-0.96]) decreased for low-income adults, while diabetes screening (RR, 1.01 [95% CI, 0.95-1.08]) remained stable. Treatment for hypertension (RR, 1.05 [95% CI, 1.02-1.08]) increased, and diabetes-focused visits and insulin use remained stable. These patterns were similar for high-income adults. Across most outcomes, there were no differential changes between low-income adults residing in Medicaid expansion versus nonexpansion states. CONCLUSIONS: In this national study of working-age adults in the United States, measures of health care access improved for low- and high-income adults in 2021. However, routine outpatient visits and cardiovascular risk factor screening did not return to prepandemic levels, while risk factor treatment remained stable. As many coronavirus disease-era safety net policies come to an end, targeted strategies are needed to protect health care access and improve cardiovascular risk factor screening for working-age adults.