Pandemic policies shrank cost-related barriers to healthcare

Pandemic-era policies protect insurance access

The Families First Coronavirus Response Act provided states with extra Medicaid funding, in turn requiring those states to halt Medicaid disenrollments during the public health emergency (PHE).

The American Rescue Plan Act (ARPA) of 2021 increased Marketplace premium tax credits for individuals with family incomes between 100 and 400% of the federal poverty level. It also extended subsidy eligibility to people with incomes over 400% of the federal poverty level. The tax credits and subsidies were intended to increase the number of people with Marketplace insurance coverage.

With improved access to health insurance coverage, policymakers intended to improve patient access to care by lessening some cost burden. But with the PHE over, the federal government's discontinuation of these policies could lead to a renewed spike in cost-related barriers to care, the researchers said.

"Our findings show significant improvements in health insurance coverage and healthcare access under federal and state policy changes enacted during the public health emergency," said Michael Karpman, principal research associate at the Urban Institute, in a public statement. "The continued unwinding of the Medicaid continuous coverage requirement and the potential expiration of enhanced Marketplace subsidies after 2025 could make these gains in coverage and access difficult to sustain."

Cost-related barriers to care go down

The researchers looked at data from the National Health Interview Survey (NHIS) from between 2019 and 2022 to assess cost-related barriers to care before, during and after the pandemic and its related policies protecting insurance coverage.

Overall, these policies were effective at protecting and even promoting insurance coverage.

During the study period, the number of individuals reporting uninsurance shrank from 14.5% to 12.4%. The number of individuals reporting continuous coverage for all 12 months of the previous year increased from 82.1% to 84.4%.

These results were more pronounced in states that had expanded Medicaid between 2019 and 2022. They were also more pronounced for adults with family incomes below 138% of the federal poverty level or between 138% and 249% of the federal poverty level.

In turn, care access -- measured as the proportion of individuals going without needed medical care due to high cost -- went up, the researchers said.

The proportion of adults reporting cost-related barriers to care declined from 12.1% to 9.7% during the study period. This shakes out to 4.75 million fewer people foregoing their healthcare because they cannot afford it.

Again, these trends were more pronounced among individuals living in states that expanded Medicaid between 2019 and 2022 (decline from 15.7% to 10% skipping care due to cost). Among folks with family incomes below 138% of the poverty level, the proportion skipping care due to cost went down from 20.3% to 14.9%, and for those with family incomes between 138% and 249% of the federal poverty level, the drop was from 18.4% to 14.9%.

Notably, the researchers observed a similar pattern when it comes to prescription drug access. Cost remains one of the largest hurdles to prescription drug access and medication adherence, but pandemic-era insurance coverage protections somewhat insulated the industry from those issues.

During the study period, the number of adults who did not get needed prescriptions because of cost, or who did not take medications as prescribed to save money, decreased from 9.8% to 7.5%.

PHE unwinding might threaten healthcare affordability

The PHE ended on May 11, 2023, signaling the end of pandemic-era protections like the Medicaid continuous coverage requirement and Marketplace tax credits and subsidies.

Per figures from KFF, at least 23,785,000 Medicaid enrollees had been disenrolled from the program as of June 28, 2024, although there could be some variation due to individual state reporting practices. Many states have also begun the process of renewing Medicaid enrollment.

According to Kathy Hempstead, a senior policy advisor at the Robert Wood Johnson Foundation, the end of the Medicaid continuous coverage rule warrants a second look.

"Access to affordable, high-quality health coverage is critical to a healthy life," Hempstead said in a statement. "Policymakers should build upon pandemic-era policies that expanded access to coverage and reduced health disparities."

Sara Heath has covered news related to patient engagement and health equity since 2015.