Racial and Ethnic Differences in Insurance Outcomes After Job Loss During the First Year of the COVID-19 Pandemic

This cohort study uses national survey data to assess the racial and ethnic differences in insurance coverage after job loss during the first year of the COVID-19 pandemic.


Introduction
Due to the COVID-19 pandemic, unemployment soared from 3.5% in February 2020 to 14.7% in April before falling to 6.7% in December. 1 Research found that uninsurance rose among working-age adults due to falling employer-sponsored insurance (ESI) among newly unemployed workers that was only partially offset by Medicaid. 2,3We assessed racial and ethnic differences in uninsurance and coverage sources among working-age adults who worked in 2019 and 2020 (continuously employed) and who worked in 2019 but were unemployed in 2020 (newly unemployed).

Methods
In this cohort study, we used 2019-2020 longitudinal data from the National Health Interview Survey (NHIS) (publicly available data not requiring informed consent).The 2019 interviews occurred throughout the year, whereas 2020 interviews occurred between August and December.The study was approved by the University of California, Los Angeles, institutional review board and followed the STROBE reporting guideline.
We used linear probability models to analyze 3 insurance outcomes: uninsurance, Medicaid, and private.We stratified analyses by participant-reported race and ethnicity (using the NHIS recode variable) of all working-age adults (18-64 years) and those with a job in 2019, comparing continuously employed and newly unemployed (eMethods in Supplement 1).Independent variables included year, person fixed effects, and interaction of employment status and year.We estimated models using survey commands accounting for weighting, stratification, and clustering at the primary sampling unit level.Statistical analyses were performed between June 2022 and January 2023, using Stata, version 17.0 software (StataCorp LLC).

Results
The Table presents demographic details and insurance coverage for the sample.Unweighted and weighted sample sizes were 4613 and 126 202 767 for continuously employed and 545 and 16 575 007 for newly unemployed participants.Compared with continuously unemployed participants, those newly unemployed were more likely to be women (61.4% vs 38.6% men) and less likely to be White (8.3% Asian, 16.6% Black, 21.9% Hispanic, 4.7% other vs 48.5% White), had lower educational attainment and income, and were less likely to be privately insured in 2019 and more likely to have Medicaid.b The "other" category included non-Hispanic American Indian or Alaska Native, with or without any other group; and other single and multiple races.A detailed explanation of how race and ethnicity were categorized is provided in the eMethods in Supplement 1.

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Uninsurance and coverage sources were unchanged from 2019 to 2020 for all working-age adults, those employed in 2019, and those continuously employed, regardless of race and ethnicity(Figure).For newly unemployed participants, private insurance declined in 2019-2020 (−11.7 [95% CI, −16.9 to −6.5] percentage points), which was only partially offset by a rise in Medicaid coverage (5.2 [95% CI, 1.1-9.3]percentage points), resulting in higher uninsurance (6.4 [95% CI, 1.7-11.1]percentage points).Findings differed by race and ethnicity: although the decline in private insurance + Supplemental content Author affiliations and article information are listed at the end of this article.Open Access.This is an open access article distributed under the terms of the CC-BY License.JAMA Health Forum.2023;4(3):e230168.doi:10.1001/jamahealthforum.2023.0168(Reprinted) March 31, 2023 1/From: https://jamanetwork.com/ on 10/01/2023 was offset by higher Medicaid coverage among newly unemployed White participants, there was no offsetting increase in Medicaid among newly unemployed Black or Hispanic participants (even when we excluded non-US-born Hispanic workers living in the US for <5 years), resulting in growth in uninsurance for both groups (Figure).