Abstract
The extant data suggest that LGBT communities were disproportionately impacted by the economic ramifications of the pandemic and were more likely to report being uninsured throughout the first two years of the pandemic. Additionally, these groups are at heightened vulnerability for several health conditions that require insurance to manage or prevent. Thus, there is a need to assess changes in pandemic-era insurance coverage among these populations. This study uses data collected as part of the Together 5,000 study, a U.S. national, internet-based cohort study of cisgender men, trans men, and trans women who have sex with men. We analyze insurance data across three different assessments between 2019 and 2021, exploring changes in insurance coverage and type. Among our sample, 6.4% lost their insurance in 2020 because of the pandemic. Insurance loss was associated with living in a state that had not expanded Medicaid, race/ethnicity, employment status, and income. Among those who lost their insurance in early 2020, most (59.2%) reported gaining insurance by 2021, with those living in non-expanded states less likely to gain insurance. Finally, those who were uninsured prior to the pandemic were less likely to report gaining insurance by 2021, when compared to those uninsured as a result of the pandemic. This suggests that there are uninsured cisgender gay and bisexual men and transgender individuals that continue to go unreached by policies to assuage uninsurance. Further policy intervention is needed to address uninsurance among LGBT individuals, which has important implications for addressing health disparities among these populations.
Keywords: Health Insurance, Health Disparities, Gay and Bisexual Men, Transgender individuals, COVID-19, Healthcare Reform, Health Policy, LGBT Health
In March 2020, the SARS-CoV-2 pandemic reached the United States, leading to the closure of many businesses, schools, and non-essential institutions along with stay-at-home orders across the U.S. In the weeks that followed, business closures led to mass employee layoffs and furloughs. The U.S. Bureau of Labor Statistics reported that by April 2020, unemployment reached a high of 14.8% (or 23.1 million unemployed), up from 3.5% in February—prior to the onset of the pandemic.1 In 2021, unemployment decreased but remained above pre-pandemic rates until recently when unemployment decreased to just above pre-pandemic rates (3.8% in February 2022).1 In addition to concerns about the implications of lost income for U.S. families, lost employment raised concerns regarding lost employer-sponsored health insurance for workers and their family members.
Early estimates of health insurance loss resulting from the pandemic were alarming, with some approximating upwards of 27 million losing employer-sponsored health insurance (ESI).2 However, survey findings have since reported more moderate insurance losses in the early months of the pandemic, although these estimates are subject to methodological error. For example, using data from the PULSE Household Survey, researchers estimated that between late-April and mid-July 2020, the overall uninsurance rate in the U.S. rose by approximately 1 percentage point from 12.9% to 13.9%, accounting for 2 million individuals losing insurance.3 However, early assessments of insurance loss did not account for lost ESI among LGBT communities, and thus did not report on the experiences of LGBT individuals in national assessments of pandemic-related uninsurance, nor provide insights into the inclusion and representation of LGBT communities among their samples. Ultimately, results from the National Health Insurance Survey (NHIS) showed that overall uninsurance rates in 2020 were not significantly different from prior years, during which uninsurance rates were steadily rising. Preliminary NHIS findings reveal that uninsurance rates in 2021 also did not differ significantly from 2020, with 14% of U.S. adults uninsured between January and June of 2021.4
Prior to the onset of the pandemic, LGBT individuals were at heightened risk for unemployment and uninsurance. For example, a Gallup Poll from 2014 revealed significantly higher uninsurance rates among LGBT persons, although these rates declined after the implementation of the ACA.5 Meanwhile, a 2018 study found that sexual minority men and women were approximately twice as likely to be uninsured and unemployed compared to their heterosexual counterparts.6 Furthermore, a survey from the Kaiser Family Foundation using data from 2017 through 2018, found that transgender (trans) adults in the U.S. were significantly more likely than their cisgender (cis) counterparts to be uninsured (19% versus 12%).7 Given these pre-existing insurance disparities that affect LGBT communities, there is a critical need to monitor and assess the ongoing secondary impacts of the pandemic on LGBT communities, including monitoring the insurance status of LGBT individuals over time.
In response to this need, The PULSE Household survey added an assessment of gender and sexual identity to their weekly surveys in 2021.8 The PULSE Household surveys are distributed by the U.S. Census Bureau in collaboration with other federal offices and have collected important economic, psychosocial and health data since the early months of the pandemic. PULSE data reveal that since the start of the pandemic, LGBT individuals have experienced disproportionately high rates of economic hardship during the COVID-19 pandemic, including food insecurity and employment/income loss .9 These findings may point to increased risk for insurance loss as a result of the pandemic for LGBT communities. Indeed, a comparison of uninsurance data from these national surveys reveals that LGBT individuals were more likely to be uninsured across data collection timepoints in 2021. For example, in December 2021, nearly 10% of U.S. LGBT adults reported being uninsured, compared to just over 7% of non-LGBT adults.10 These data only reveal whether one is insured at a given point in time. However, individuals can have a range of insurance experiences, and may be insured through a publicly financed insurance program (i.e., Medicare, Medicaid) or through a private insurance provider through their employer or the insurance Marketplaces. Finally, individuals can move through different insurance programs and insurance statuses over time, as their economic, employment and social circumstances shift. Assessing these varied insurance experiences can offer insight into how existing policies (i.e., ACA’s Medicaid expansion), and pandemic-era policies (i.e., Families First Coronavirus Response Act, American Rescue Plan Act, and state-level policies) helped to—or failed to—mitigate insurance loss as a result of the pandemic and its secondary economic effects.
In this study, we focus on cis gay and bisexual men, as well as trans individuals because of the range of unique physical and mental health challenges they experience, and because of the limited data on the insurance experiences for these populations. For example, gay and bisexual men, as well as trans individuals (particularly trans women) are at elevated risk for HIV,11 which can be prevented with pre-exposure prophylaxis (PrEP),12 but PrEP requires consistent medical care. Additionally, gay and bisexual men and trans individuals (GBT) experience mental health challenges,13,14 substance use disorders,15,16 sexually transmitted infections,17–20 and several cancers and chronic diseases at higher rates than their heterosexual and cisgender counterparts.21–23 Also concerning, GBT individuals experience high rates of suicidal ideation, self-harm and attempted suicide.23–25 It is worth noting that GBT individuals face unique healthcare access issues, beyond insurance and cost-related barriers. However, lost ESI as a result of the COVID-19 pandemic could exacerbate existing disparities in health and further impair access to healthcare among these populations. Consistent access to high quality, culturally appropriate care is integral to meeting the healthcare needs of GBT communities, access to which is often contingent upon insurance coverage.
In sum, further exploration of insurance rates among GBT persons, as well as the effects of the COVID-19 pandemic on insurance coverage is needed. This study uses data from a U.S. national cohort study of cis gay and bisexual men, trans men, trans women and nonbinary individuals. We analyze insurance losses and changes throughout the first year of the pandemic into 2021, as well as observe between group differences in Medicaid expanded- versus non-expanded states.
METHODS
Cohort Recruitment, Enrollment, and Surveys
This study uses data collected as part of the Together 5,000 study, a U.S. national, internet-based cohort study of men, trans men, and trans women who have sex with men. The cohort has been described in detail elsewhere.26,27 In brief, enrollment began October 2017 using ads on men-for-men geosocial sexual networking phone applications and concluded in June 2018. Eligibility criteria specified that participants were men, trans men, or trans women; aged 16 to 49 years; and vulnerable to HIV (See Nash et al. for full study criteria). In brief, participants were HIV negative, not on PrEP, and reported sex with two or more male partners in the 90 days prior to enrollment. Moreover, participants met one additional criterion that put them at heightened vulnerability for HIV, which related to engaging in either condomless sex, injection drug use, methamphetamine use, or a recent STI diagnosis. Of note, our recruitment strategies were targeted to reach cis men who have sex with men, but our enrollment criteria did not exclude trans individuals who otherwise met study criteria.
Participants clicking one of our ads were routed from the sexual networking apps to a secured, informed consent and enrollment survey web page that collected information on eligibility criteria. Although there was no compensation for completing the enrollment survey, consented and enrolled participants were invited to complete subsequent study procedures (e.g., an additional survey, at-home HIV testing) that were incentivized.
Participants in the cohort receive annual assessments. For the present study, we use data from those who completed their annual 2019-assement, COVID-19 supplemental assessment (in 2020), and 2021-assessment. In total, 3,230 participants completed all three assessments and were thus included in our analysis. For the present analysis, we examine insurance changes among cis men, trans men, trans women and non-binary individuals (assigned male sex at birth) who have sex with men.
Study Measures
Variables of interest for the current study included participant demographics, insurance coverage (yes/no), type of insurance (private insurance, Medicaid or Medicare for those who qualify due to disability, other government-sponsored insurance), and state of residence to determine Medicaid expansion status.
Analysis Plan
We describe frequencies and percentages for insurance status, including uninsurance, type of insurance and lost insurance across time points to illustrate the change in insurance coverage following the onset of the COVID-19 pandemic. We perform these analyses to explore changes in insurance coverage and type during the first two years of the pandemic.
First, we assess those most likely to lose their health insurance during the early months of the pandemic, and report characteristics associated with lost insurance, including demographic and geographic characteristics associated with insurance loss. Acknowledging that insurance status is fluid and can change over time, we then follow two groups to assess their insurance status during their annual assessment in 2021. These groups were those who did not report losing their insurance during the early months of the pandemic, and those that did. Furthermore, we assess whether insured individuals moved from a private insurance plan to publicly funded one, and conversely, to reach a better understanding of the insurance changes that occurred during 2020/2021.
Additionally, we tested differences in insurance coverage and type of insurance, between those residing in states that expanded Medicaid in accordance with ACA funding requirements, and those that have not expanded as of January 1st, 2020, using chi-square tests. Finally, using a chi square test, we compare those who lost their insurance during the early months of the pandemic, against those who were previously uninsured prior to the pandemic’s onset, to examine whether these groups would fare differently in gaining insurance by 2021. We contextualize these findings within a larger discussion of insurance churn in the United States throughout the pandemic. Understanding both changes in insurance status, and insurance type (public/private), as well as comparisons among different uninsured groups has important policy implications that can be used to guide strategies for reducing uninsurance during this later phase of the pandemic. All analyses were performed using SAS.
RESULTS
In total, 3,230 participants were included in our sample. During their 2020 assessment, participants were on average 35.5 years old (SD = 7.88), with a range from 20 to 53 years old. In total, 55.3% of participants were white (n = 1786), 23.5% were Latino/Latinx (n = 758), 9.5% were Black (n = 306), 6.9% were Multiracial (n = 223), 3.8% were Asian (n = 124) and 1.0% American Indian or Alaska Native (n = 33). In total, 86.6% reporting their sexual orientation as gay or queer (n = 2798), while 12.5% reported being bisexual (n = 405). Most participants were cisgender male (96.7%, n = 3213), 2.1% of participants were non-binary (n = 69), and the remaining participants identified as trans male, trans female or selected “something else.” Nearly 14.9% of participants reported their income was below $10,000 per year, while 29.8% made between $10,000 and $29,999 and the remaining participants made above $30,000 per year. Finally, 45.6% of participants were residing in the Southern region of the U.S., while 23% were from the West, 15.7% from the North and 15.7% from the Midwest. Table 1 provides a detailed overview of the demographics for the sample.
Table 1.
Demographic characteristics of participants by COVID-19 related insurance loss in 2020
| Total 3230 | Lost insurance due to COVID n = 206 | Did not lose insurance n = 2829 | Not applicable n = 195 | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Frequency | (%) | Frequency | (%) | Frequency | (%) | Frequency | (%) | Chi-square | p | |
| Race/ethnicity | 51.03 | <.0001 | ||||||||
| White | 1786 | (55.3) | 91 | (5.1) | 1621 | (90.8) | 74 | (4.1) | ||
| American Indian, Alaska Native Hawaiian | 33 | (1.0) | 2 | (6.1) | 30 | (90.9) | 1 | (2.9) | ||
| Asian | 124 | (3.8) | 6 | (4.8) | 111 | (89.6) | 7 | (5.6) | ||
| Black | 306 | (9.5) | 28 | (9.2) | 259 | (84.6) | 19 | (6.2) | ||
| Other MultiRacial | 223 | (6.9) | 15 | (6.7) | 186 | (83.5) | 22 | (9.8) | ||
| Latino/Latinx | 758 | (23.5) | 64 | (8.4) | 622 | (82.1) | 72 | (9.5) | ||
| Gender | 7.2335 | 0.5117 | ||||||||
| Male (cis male) | 3213 | (96.7) | 199 | (6.4) | 2737 | (87.6) | 187 | (6.0) | ||
| Trans female | 8 | (0.3) | 0 | (0.0) | 8 | (100.0) | 0 | (0.0) | ||
| Trans male | 19 | (0.6) | 2 | (10.5) | 17 | (89.5) | 0 | (0.0) | ||
| Non-binary | 69 | (2.1) | 5 | (7.3) | 58 | (84.1) | 6 | (8.7) | ||
| Something else | 11 | (0.3) | 0 | (0.0) | 9 | (81.8) | 2 | (18.2) | ||
| Sexual Orientation | 8.23 | 0.0834 | ||||||||
| Gay, Queer, Homosexual | 2798 | (86.6) | 181 | (6.5) | 2461 | (88.0) | 156 | (5.6) | ||
| Bisexual | 405 | (12.5) | 23 | (5.7) | 345 | (85.2) | 37 | (9.1) | ||
| Other (Straight, Heterosexual) | 27 | (0.8) | 2 | (7.4) | 23 | (85.2) | 2 | (7.4) | ||
| US Region | 10.57 | 0.10 | ||||||||
| Northeast | 506 | (15.7) | 27 | (5.3) | 450 | (88.9) | 29 | (5.7) | ||
| Midwest | 506 | (15.7) | 23 | (4.6) | 462 | (91.3) | 21 | (4.2) | ||
| South | 1474 | (45.6) | 105 | (7.1) | 1270 | (86.2) | 99 | (6.7) | ||
| West | 744 | (23.0) | 51 | (6.9) | 647 | (87.0) | 46 | (6.2) | ||
| Income during early 2020 | 81.20 | <.0001 | ||||||||
| Less than 10,000 | 480 | (14.9) | 27 | (5.6) | 394 | (82.1) | 59 | (12.3) | ||
| $10,000-$29,999 | 962 | (29.8) | 68 | (7.1) | 815 | (84.7) | 79 | (8.2) | ||
| $30,000-$49,999 | 847 | (26.2) | 63 | (7.4) | 748 | (88.3) | 36 | (4.3) | ||
| 50,000-$74,999 | 490 | (15.2) | 33 | (5.1) | 444 | (90.6) | 13 | (2.7) | ||
| $75,000 or more | 451 | (14.0) | 15 | (3.3) | 428 | (94.9) | 8 | (1.8) | ||
| Employment during early 2020 | 95.56 | <.0001 | ||||||||
| Full-time (40 hours per week) | 2180 | (67.5) | 142 | (6.5) | 1961 | (90.0) | 77 | (3.5) | ||
| Part-time (less than 40 hours per week) | 364 | (11.3) | 23 | (6.3) | 299 | (82.1) | 42 | (11.5) | ||
| Working or full-time student | 424 | (13.1) | 15 | (3.5) | 371 | (87.5) | 38 | (8.9) | ||
| Unemployed/Other | 262 | (8.1) | 26 | (9.9) | 198 | (75.6) | 38 | (14.5) | ||
| Live in a Medicaid expansion state | 9.27 | 0.01 | ||||||||
| No Medicaid Expansion | 1368 | (42.4) | 101 | (7.4) | 1170 | (85.5) | 97 | (7.1) | ||
| Medicaid Expansion | 1862 | (57.7) | 105 | (5.6) | 1659 | (89.1) | 98 | (5.3) | ||
| N | Mean | Std Dev | Range | Min | Max | |||||
| Age | 3230 | (35.5) | 7.88 | (33.0) | (20.0) | (53.0) | ||||
Who lost their insurance in 2020 because of COVID-19?
Between April and May of 2020, 6.4% (n = 206/3230) of participants reported that they experienced a personal loss of health insurance because of the COVID-19 pandemic. There were significant racial/ethnic differences in insurance loss due to COVID-19, with Black and Latinx participants the most likely to report insurance loss (9.2% and 8.4% respectively), while white participants (5.1%) were the least likely to report an insurance loss (see Table 1). Insurance loss due to COVID-19 did not significantly differ by sexual orientation or gender identity. However, COVID-19 related uninsurance was associated with income level and employment status during 2020 (see Table 1). Those making between $10,000 to $29,000, and $30,000 to $49,000 dollars per year were the most likely to report insurance losses (7.1% and 7.4%, respectively), with those making over $75,000 (3.3%) the least likely to report losing their insurance. Notably, those in the lowest income group (less than $10,000 per year) were also less likely to report losing their insurance (5.6%) compared to more moderate-income groups, likely a result of higher rates of Medicaid coverage among this group. Those who were unemployed during the early months of the pandemic were most likely to report losing their insurance (9.9%), while those who reported being a student were the least likely to report an insurance loss resulting from COVID-19 (3.5%). However, in absolute numbers, those reporting full-time employment made up the majority of those who lost insurance (6.5%, n = 142). Finally, participants reporting a loss of insurance due to COVID-19 were significantly more likely to reside in states that have not expanded Medicaid (7.4%) versus states that have expanded (5.6%). See Table 1 for full description of between group differences.
Following those who did not lose their insurance in 2020 into 2021…
Of those who did not report losing their insurance because of the early pandemic (n = 2,829), 85.2% (n = 2,410) remained insured at their 2021 annual assessment, with 13.6% (n = 384) reporting uninsurance and 1.2% (n = 35) unsure of their insurance status (see Table 2 for descriptive analysis). Those who reported being uninsured in 2021 were significantly more likely to be residing in states that have not expanded Medicaid (19.0%, n = 222), compared those that have expanded (9.8%, n = 162). Among this same group, 3.1% (n = 64) of persons, switched from a private insurance plan to a publicly financed one (i.e., Medicaid/Medicare or other government financed plan), while 3.8% (n = 78) switched from a public to private insurance plan. Both participants who reported switching to public insurance and those switching to private insurance were significantly more likely reside in states that expanded Medicaid (4.1%, n = 52 and 5.1%, n = 65, respectively), suggesting more insurance changes occurred in states that have expanded Medicaid. Of note, 781 individuals were excluded from this analysis, due to either not having insurance at their 2019 and/or 2021 annual assessment, or they did not specify their insurance type.
Table 2.
Insurance status during 2021 and distribution by Medicaid expansion among participants who did not lose insurance due to COVID-19 in 2020
| Total 2829 | No Medicaid Expansion n = 1170 | Medicaid Expansion n = 1659 | ||||||
|---|---|---|---|---|---|---|---|---|
| Frequency | (%) | Frequency | (%) | Frequency | (%) | Chi-squared | p | |
| Health insurance status in 2021 | 56.45 | <.0001 | ||||||
| No | 384 | (13.6) | 222 | (19.0) | 162 | (9.8) | ||
| Yes | 2410 | (85.2) | 943 | (80.5) | 1468 | (88.5) | ||
| I do not know | 35 | (1.2) | 6 | (0.5) | 29 | (1.8) | ||
| aSwitched from Private to Public insurance in 2021 | 10.47 | 0.0012 | ||||||
| Yes | 64 | (3.1) | 12 | (1.5) | 52 | (4.1) | ||
| No | 1984 | (96.9) | 768 | (98.3) | 1216 | (95.9) | ||
| aSwitched from Public to Private insurance in 2021 | 15.75 | <.0001 | ||||||
| Yes | 78 | (3.8) | 13 | (1.7) | 65 | (5.1) | ||
| No | 1970 | (96.2) | 767 | (98.3) | 1203 | (94.9) | ||
781 were excluded from the analyses as they did not have insurance or did not specify insurance type
Following those who lost their insurance in 2020 into 2021…
Of those who reported insurance loss because of COVID-19 in early 2020 (n = 206), 59.2% (n = 122) gained insurance coverage by 2021, and 38.8% (n = 80) remained uninsured at their 2021 assessment (see Table 3). Among those who gained health insurance (n = 122), 72.1% (n = 88) reported gaining private health insurance, and 23.8% (n = 29) gained publicly financed insurance through Medicaid or Medicare. Participants who gained insurance by 2021 were more likely to reside in Medicaid-expanded states (74.3%, n = 78), compared to non-expanded states (43.6%, n = 44), see Table 3.
Table 3.
Distribution of insurance gain in 2021 by Medicaid expansion among participants who reported insurance loss due to COVID-19 in 2020
| Total N = 206 | No Medicaid Expansion n = 101 | Medicaid Expansion n = 105 | ||||||
|---|---|---|---|---|---|---|---|---|
| Frequency | (%) | Frequency | (%) | Frequency | (%) | Chi-squared | p | |
| Health insurance in 2021 | 20.66 | <.0001 | ||||||
| No | 80 | (38.8) | 55 | (54.5) | 25 | (23.8) | ||
| Yes | 122 | (59.2) | 44 | (43.6) | 78 | (74.3) | ||
| I do not know | 4 | (1.9) | 2 | (2.0) | 2 | (1.9) | ||
| aHealth insurance type | 18.711 | 0.00 | ||||||
| Private Insurance (e.g. Blue Cross/Blue Shield, United, Kaiser) | 88 | (72.1) | 42 | (95.5) | 46 | (59.0) | ||
| Some other government program (e.g. TriCare, tribal health care) | 2 | (1.6) | 0 | (0.0) | 2 | (2.6) | ||
| Medicaid/Medicare | 29 | (23.8) | 2 | (4.6) | 27 | (34.6) | ||
| Other (please specify): | 0 | (0.0) | 0 | (0.0) | 0 | (0.0) | ||
| Don’t know/Not sure | 3 | (2.5) | 0 | (0.0) | 3 | (3.9) | ||
84 were excluded because they did not report insurance gain in 2021
Following those who were uninsured prior to the pandemic into 2021…
Of those that completed all three assessments, 649 reported being uninsured prior to the onset of the pandemic in the U.S. (during their 2019 assessment). Among this group, only 45.5% (n = 295) reported gaining insurance by 2021, with 52.9% (n = 343) remaining uninsured in 2021 (see Table 4). Of those who were uninsured prior to COVID-19 who gained health insurance, 68.5% (n = 202) reported gaining private health insurance, and 22.7% (n = 67) gained publicly financed insurance through Medicaid or Medicare. Participants who gained insurance by 2021 were more likely to reside in Medicaid-expanded states (55.5%, n = 161), compared to non-expanded states (37.3%, n = 134).
Table 4.
Distribution of insurance gain in 2021 by Medicaid expansion among those uninsured in 2019
| Total N = 649 | No Medicaid Expansion n = 359 | Medicaid Expansion n = 290 | ||||||
|---|---|---|---|---|---|---|---|---|
| Frequency | (%) | Frequency | (%) | Frequency | (%) | Chi-squared | p | |
| Health insurance in 2021 | 24.81 | <.0001 | ||||||
| No | 343 | (52.9) | 221 | (61.6) | 122 | (42.1) | ||
| Yes | 295 | (45.5) | 134 | (37.3) | 161 | (55.5) | ||
| I do not know | 11 | (1.7) | 4 | (1.1) | 7 | (2.4) | ||
| Health insurance typea | 30.68 | <.0001 | ||||||
| Private Insurance (e.g. Blue Cross/Blue Shield, United, Kaiser) | 202 | (68.5) | 110 | (82.1) | 92 | (57.1) | ||
| Some other government program (e.g. TriCare, tribal health care) | 10 | (3.4) | 5 | (3.7) | 5 | (3.1) | ||
| Medicaid/Medicare | 67 | (22.7) | 11 | (8.2) | 56 | (34.8) | ||
| Other (please specify): | 1 | (0.3) | 0 | (0.0) | 1 | (0.6) | ||
| Don’t know/Not sure | 15 | (5.1) | 8 | (6.0) | 7 | (4.4) | ||
354 were excluded because they did not report insurance gain in 2021
How do those who lost their insurance in 2020, compare to those who were uninsured prior to the pandemic?
Participants who reported losing their insurance because of the pandemic in 2020, were significantly more likely to regain coverage by 2021 (59.2%, n = 122), when compared to those uninsured prior to the pandemic’s onset (47%, n = 277, see Table 5). For this analysis, we coded 55 participants who reported both being uninsured in 2019 and losing their insurance as a result of COVID-19 as “uninsured due to COVID-19”.
Table 5.
Comparison of insurance gain in 2021 between those who lost insurance due to COVID-19 and those uninsured pre-pandemic (2019)
|
Health Insurance in 2021
|
|||||||||
|---|---|---|---|---|---|---|---|---|---|
| Totala N=796 | No n = 383 | Yes n = 399 | Don’t know n=14 | ||||||
| Frequency | % | Frequency | (%) | Frequency | (%) | Frequency | (%) | p | |
| 0.0082 | |||||||||
| Uninsured due to COVID-19 | 206 | (25.9) | 80 | (38.8) | 122 | (59.2) | 4 | (1.9) | |
| Uninsured in 2019 | 590b | (74.1) | 303 | (51.4) | 277 | (47.0) | 10 | (1.7) | |
2436 people were excluded from the analysis because they were either insured or did not know their insurance status
55 participants who reported both being uninsured in 2019 and losing their insurance as a result of COVID-19 were coding as “uninsured due to COVID-19”
DISCUSSION
Although the Affordable Care Act’s (ACA) safety-net features like Medicaid expansion and premium subsidies for Marketplace plans are likely to have offset some of the impact of the pandemic on insurance coverage, temporary COVID-19-related policies are believed to have counteracted the effects of lost ESI in 2020 and 2021.28,29 As part of the Families First Coronavirus Response Act passed in 2020, a federal mortarium on Medicaid disenrollment (referred to as “continuous eligibility”) went into place for many states contingent on the pandemic being classified as an emergency.30 Furthermore, many states extended Medicaid and Marketplace enrollment periods, making it easier for individuals who lost coverage to sign up for Medicaid or an individual private plan.30 In 2021, the American Rescue Plan Act temporarily increased Marketplace subsidies and subsidized COBRA coverage for those who lost ESI during the pandemic.28,30 The extant literature suggest that these policies were largely successful attempts to mitigate unprecedented uninsurance during a time of recession and public health emergency.31,32 However, these solutions were not permanent, with some policies having already expired or expected to expire as of the time this manuscript was written. For example, as of March 31st 2022, Medicaid’s continuous enrollment is set to expire in mid-April, at which point millions of individuals could lose insurance coverage.33
These safety net and emergency policies may have been particularly imperative for GBT individuals who faced disproportionate employment and income precarity during the first two years of the pandemic. Our findings suggest that among our U.S. national sample of cis gay and bisexual men, trans men, trans women and non-binary individuals, 6.4% lost health insurance between March and May of 2020, because of the pandemic. This rate is higher than many estimates of insurance loss in the general population, including the Household Pulse Survey, which estimated that uninsurance rose by around 1 percentage point between April and July of 2020.3 Moreover, during our 2021 assessment, we found that an additional 384 individuals (or 11.8% of the total sample) became uninsured, all of whom were insured during the early months of the pandemic. This too suggests that GBT individuals continued to experience health insurance precarity in 2021, despite pandemic-related policies to minimize uninsurance. All told, it is likely that the rolling back of pandemic-era insurance policies will have a disproportionate impact on GBT communities.
Our findings reveal that those who lost their insurance because of the pandemic were more likely to regain insurance when compared to those uninsured prior to the pandemic. It is possible that those who lost their insurance during the pandemic were more likely to regain employment that provided health insurance or were more likely to be eligible for and/or to utilize public resources like Medicaid or Marketplace subsidies to gain insurance coverage. This suggests that while pandemic-related insurance policy changes remedied uninsurance for some, they failed to ensure coverage for many who previously fell through the cracks in our insurance system. For example, those living in states that have not expanded Medicaid often fall between the gap of qualifying for Medicaid and qualifying for Marketplace subsidies.34 These individuals likely remained unreached by pandemic-era policies. The Build Back Better Act proposes to address this coverage gap by expanding federal subsidies for Marketplace plans in non-Medicaid expanded states, should it become law—and would thus have important implications for the healthcare coverage of low-income GBT individuals.33
Indeed, in our study, insurance loss during COVID-19, uninsurance prior to COVID-19 and gaining insurance in 2021– were all associated with state-level Medicaid expansion status; with those residing in non-expanded states facing higher rates of insurance loss and lower rates of insurance gain across time points. This is unsurprising, as non-expansion states have higher rates of uninsurance for the general population when compared to states that have expanded Medicaid under the ACA (15.5% versus 8.3% in 2019).35 Furthermore, in expanded states, continuous Medicaid eligibility likely had an outsized effect on curtailing uninsurance during the pandemic.33 Further extensions of continuous Medicaid eligibility would benefit low-income persons moving forward, including GBT individuals who benefit from the program. Additionally, further expansions to Marketplace subsidies and Medicaid eligibility at the state-level could improve insurance coverage for those who continue to fall through the coverage gap. Finally, more comprehensive expansions of public health insurance, like expanding Medicare eligibility and incrementally implementing a publicly financed single-payer insurance system, could help to close coverage gaps in the U.S., while moving the U.S. toward a truly universal healthcare system.
Disproportionately high pre-existing uninsurance and unemployment rates among LGBT individuals likely mean that our participants were uniquely at risk for uninsurance during the ongoing pandemic. The Kaiser Family Foundation found that since February 2020, 56% of LGBT Americans reported income or job-loss in their household, compared to 44% of non-LGBT Americans.36 The PULSE Household Survey similarly revealed high rates of economic hardship among LGBT individuals during the pandemic; 13% of LGBT respondents reported experiencing food insecurity in the past week, compared to 7% of non-LGBT respondents, and almost one-in-five reported living in a household with someone who lost employment income in the past month, compared to 17% of non-LGBT adults.9 These economic disparities have continued to show up in PULSE assessments during 2021, along with persisting insurance coverage disparities.10,37,38 These findings, as well as our own, suggest that LGBT individuals have been disproportionately impacted by the economic effects of the pandemic. Policies that assuage the economic ramifications of the pandemic, including policies that extend insurance coverage, are likely to have a disproportionately protective benefit for LGBT individuals and families.
Finally, higher rates of lost insurance among GBT individuals may have important implications for tackling health disparities that effect these populations. For example, having insurance makes accessing HIV prevention strategies like PrEP easier, despite programs for those who do not have insurance.39 Studies have found that lack of insurance creates barriers PrEP uptake among gay and bisexual men, and that those who are uninsured are less likely to begin PrEP.39,40 Additionally, mental health care and substance use treatment is made more accessible for those who are insured. For example, findings from the National Survey on Drug Use and Health found that those with an unmet treatment need for mental health care and substance use treatment were more likely to be uninsured.41 Finally, high quality insurance coverage is critical for improving access to gender-affirming care for trans individuals, access to which can be psychologically protective.42–44 Indeed, studies support that expanded insurance coverage as a result of the Affordable Care Act increased access to health care, improved health outcomes, and resulted in lower mortality rates among some groups.45 Taken together, these findings support that additional measures to expand health insurance would improve health outcomes for GBT communities, while helping to minimize existing health disparities.
Limitations
Our findings should be interpreted with consideration for their limitations. Most of our sample was comprised of white, cisgender gay and bisexual men. Thus, our study was not adequately powered to perform between group analyses to assess the various changes in insurance status among trans individuals and people of color, groups that are disproportionately impacted by uninsurance. It is likely that those experiencing intersecting marginalized identities shoulder the worst health insurance losses because of social and economic marginalization. Studies and interventions that hope to understand and intervene upon uninsurance and underinsurance among LGBT individuals will require additional data to understand how diverse sexual and gender minority groups experience insurance loss, as well as its impact on their health and financial wellbeing.
Our study assessed changes in insurance status and type over a two-year period. However, future research should consider additional measures of insurance coverage and affordability. For example, the extant literature suggests that many insured individuals face prohibitive cost-related barriers to care, including high deductibles and copays, as well as challenges paying monthly insurance premiums.46 Moreover, bureaucratic hurdles to Medicaid enrollment create additional challenges for low-income persons hoping to secure insurance coverage.47 These issues should be assessed specifically for their effect on LGBT individuals, and subsequent impact on health and healthcare disparities among these groups.
Finally, we categorized participants as residing in a Medicaid expansion state as of January 1st, 2020, however Nebraska has since expanded eligibility in November of 2020 (after data collection for our COVID-19 assessment, but before out annual assessment in 2021). Thus, participants from Nebraska (n = 15) are misclassified as residing in a non-expanded state for their 2021 insurance assessment, as our primary variable of interest (COVID-19-related insurance loss) was assessed prior to their expansion.
Conclusions
Among our U.S. national sample of cisgender gay and bisexual men, as well as transgender individuals who have sex with men, we found higher rates of lost insurance during the first year of the pandemic, than those reported for the general population. Across timepoints, those residing in states that expanded their Medicaid program were more likely to have been protected from insurance loss during the pandemic. Finally, those who reported being uninsured prior to the pandemic were more likely to remain uninsured in 2021, when compared with those who lost their insurance during the pandemic, suggesting that perpetually uninsured groups continue to fall through the gaps in our insurance system, despite policy changes during the COVID-19 pandemic.
PUBLIC HEALTH SIGNIFICANCE.
The COVID-19 pandemic led to insurance losses among cisgender gay and bisexual men, as well as transgender individuals, which may have been partly ameliorated by pandemic-specific polices to address uninsurance. However, individuals who were uninsured prior to the pandemic may be less likely to experience the benefits of these policies; necessitating further action to address uninsurance among these vulnerable individuals.
Acknowledgements:
Special thanks to additional members of the T5K study team: Denis Nash, David Pantalone, Sarit A. Golub, Viraj V. Patel, Gregorio Millett, Don Hoover, Sarah Kulkarni, Matthew Stief, Chloe Mirzayi & Michelle Dearolf. Thank you to the program staff at NIH: Gerald Sharp, Sonia Lee, and Michael Stirratt. And thank you to the members of our Scientific Advisory Board: Michael Camacho, Demetre Daskalakis, Sabina Hirshfield, Claude Mellins, and Milo Santos. While the NIH financially supported this research, the content is the responsibility of the authors and does not necessarily reflect official views of the NIH.
Funding:
Together 5,000 was funded by the National Institutes for Health (UH3 AI 133675 - PI Grov). Other forms of support include the CUNY Institute for Implementation Science in Population Health, the Einstein, Rockefeller, CUNY Center for AIDS Research (ERC CFAR, P30 AI124414).
Footnotes
Ethics and Consent Statement: All procedures were approved by the IRB of The City University of New York [approval # 2017-0893]. Participants provided written informed consent before participating in this study.
Conflict of Interest Statement: The authors report no conflicts of interest.
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