The Medicaid expansion in the age of COVID-19: Effects on coverage, access, use, financial stress, and health.

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Abstract The COVID-19 pandemic has posed an unprecedented threat to the health and well-being of Americans, especially low-income and minority Americans and those in poor health or who lost jobs in the economic downturn. The proposed project will examine the protective effect of access to affordable health insurance for poor and low-income Americans in the setting of major health, economic, and social disruptions to their lives. Access to affordable health insurance differs across states because only 35 states and the District of Columbia have adopted the Medicaid expansion to all working-age adults with incomes below 138% of poverty permitted under the Affordable Care Act. The proposed project has three Specific Aims: Aim 1. To assess the protective effects of the Medicaid expansion on insurance coverage for adults and children following the onset of the COVID-19 pandemic. Aim 2. To assess the protective effects of the Medicaid expansion on access to and use of health care, health care expenditures, and financial stress following the onset of the COVID-19 pandemic. Aim 3. To assess the protective effects of the Medicaid expansion on health outcomes, including physical and mental health, for adults and children following the onset of the COVID-19 pandemic. We will also assess how the protective effects differ for disadvantaged persons including poor and low- income persons, African Americans and Hispanics, persons in poor health, and persons who lose their jobs. We will employ two complementary national surveys—the National Health Interview Survey (NHIS) and the Medical Expenditure Panel Survey (MEPS)—in a phased analysis of data straddling the onset of the pandemic. NHIS covers numerous outcomes, with especially detailed measures of financial stress, children's mental health, and some health behaviors. MEPS has more detailed measures of adults' mental health and health care use and expenditures, and its panel design enables us to use analytic methods that more comprehensively control for subjects' characteristics. However, MEPS data are not available until later. We will use regression analysis to model the study outcomes as functions of individual characteristics; baseline state characteristics; time-varying local area characteristics including pandemic severity, depth of the economic downturn, state policies intended to slow spread of the pandemic, and adherence to social distancing; and interactions between states' Medicaid expansion status and local area characteristics. Our approach will enable us to quantify the protective effects of the Medicaid expansion on the study outcomes and assess the main pathways through which these effects occur. The proposed project will assess the value of access to affordable health insurance for poor and low-income persons during the COVID-19 pandemic, but its lessons will be generalizable to other recessions and public health crises, natural and man-made disasters, and people who experience health or economic setbacks in normal times.