Association between state Medicaid expansion status and health outcomes during the COVID‐19 pandemic

OBJECTIVE: To assess post‐COVID‐19 changes in insurance coverage, health behaviors, and self‐assessed health among low‐income, non‐elderly adults by state Medicaid expansion status. DATA SOURCES: We used nationally representative survey data from the 2016 through 2020 Behavioral Risk Factor Surveillance System (BRFSS). The sample was restricted to adults aged 19–64 with household income below 138 percent of the federal poverty level (N = 179,135). STUDY DESIGN: We examined a broad set of outcomes related to coverage, health behaviors, and self‐assessed health available in the BRFSS. We used a difference‐in‐differences model to compare changes in outcomes for individuals living in the 35 states and DC that expanded Medicaid under the Affordable Care Act to those in the 15 non‐expansion states before and after the COVID‐19 pandemic commenced in March 2020. DATA COLLECTION/EXTRACTION METHODS: N/A. PRINCIPAL FINDINGS: We found that the expansions provided some protection for low‐income people during the pandemic. In 2020, relative to earlier years, people in expansion states were more likely to report very good or excellent health (4.9 percentage points, 95%CI = 0.022, 0.076; p < 0.01) and physical health (−0.393 days of poor physical health in the past month, 95%CI = −0.714, −0.072; p < 0.05), lower rates of smoking (−1.9 percentage points, 95%CI = −0.041, 0.004; p < 0.10) and heavy drinking (−1.4 percentage points, 95%CI = −0.025, −0.004; p < 0.01), and higher flu vaccination rates (2.8 percentage points, 95%CI = 0.005, 0.051; p < 0.05) than those in non‐expansion states. These benefits were particularly salient for Black and Hispanic individuals. We found no significant differences in insurance coverage, exercise, obesity, and self‐assessed mental health between expansion and non‐expansion states for the overall low‐income sample. However, the expansion was associated with greater insurance coverage for Hispanic adults during the pandemic. CONCLUSIONS: Investments in public health through expanding Medicaid may shield low‐income populations from some of the health ramifications of public health emergencies.