Did Medicaid slow declines in access to health care during the great recession?

ObjectiveWe examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007‐2009 Great Recession.Data Source2004‐2010 Behavioral Risk Factor Surveillance System (BRFSS).Study DesignFlexible difference‐in‐difference regressions were used to compare the impact of county‐level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines.Data Collection/Extraction MethodsNonelderly adults (aged 19‐64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics’ Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state''s 2007 Medicaid guidelines using data from the 2007 Current Population Survey''s Annual Social and Economic Supplement.Principal FindingsA percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9‐1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6‐1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county‐level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost—a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines.ConclusionsIncreased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income.     

Medicaid expansions,preconception insurance,and unintended pregnancy among new parents

ObjectiveTo assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first‐time parents.Data SourceThis study used individual‐level data from the national Pregnancy Risk Assessment Monitoring System (2006‐2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy.Study DesignOutcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female‐identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year.Data Collection/Extraction MethodsThe sample included all individuals aged 20‐44 with a first live birth in 2009‐2017.Principal FindingsAmong all first‐time parents, a 10‐percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high‐school degree or less.ConclusionsIncreasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first‐time parents.     

Behavioral health home impact on transitional care and readmissions among adults with serious mental illness

ObjectiveTo evaluate the impact of Maryland''s behavioral health homes (BHHs) on receipt of follow‐up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI).Data SourcesMaryland Medicaid administrative claims for 12 232 individuals.Study DesignWeighted marginal structural models were estimated to account for time‐varying exposure to BHH enrollment and time‐varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow‐up care within 7 and 30 days following hospitalization.Data Collection/Extraction MethodsEligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21‐64 years; and use of psychiatric rehabilitation services.Principal FindingsOver three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow‐up service within 7 days of discharge from a mental illness–related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow‐up within 7 days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission.ConclusionsBHHs may improve follow‐up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.     

Changes in health insurance coverage,access to care,and health services utilization by sexual minority status in the United States, 2013‐2018

ObjectiveTo examine the changes in health insurance coverage, access to care, and health services utilization among nonelderly sexual minority and heterosexual adults between pooled years 2013‐2014 and 2017‐2018.Data SourcesData on 3223 sexual minorities (lesbians, gay men, bisexual individuals, and other nonheterosexual populations) and 86 181 heterosexuals aged 18‐64 years were obtained from the 2013, 2014, 2017, and 2018 National Health Interview Surveys.Study DesignUnadjusted and regression‐adjusted estimates compared changes in health insurance status, access to care, and health services utilization for nonelderly adults by sexual minority status. Regression‐adjusted changes were obtained from logistic regression models controlling for demographic and socioeconomic characteristics.Principal FindingsUninsurance declined for both sexual minority adults (5 percentage points, P < .05) and heterosexual adults (2.5 percentage points, P < .001) between 2013‐2014 and 2017‐2018. Reductions in uninsurance for sexual minority and heterosexual adults were associated with increases in Medicaid coverage. Sexual minority and heterosexual adults were also less likely to report unmet medical care in 2017‐2018 compared with 2013‐2014. Low‐income adults (regardless of sexual minority status) experienced relatively large increases in Medicaid coverage and substantial improvements in access to care over the study period. The gains in coverage and access to care across the study period were generally similar for heterosexual and sexual minority adults.ConclusionsSexual minority and heterosexual adults have experienced improvements in health insurance coverage and access to care in recent years. Ongoing health equity research and public health initiatives should continue to monitor health care access and the potential benefits of recent health insurance expansions by sexual orientation and sexual minority status when possible.     

COVID‐19‐related Medicaid enrollment in Medicaid expansion and non‐expansion states

Research ObjectiveTo explore whether expanded Medicaid helps mitigate the relationship between unemployment due to COVID and being uninsured. Unanticipated unemployment spells are generally associated with disruptions in health insurance coverage, which could also be the case for job losses during the COVID‐19 pandemic. Expanded access to Medicaid may insulate some households from long uninsurance gaps due to job loss.Data SourcePhase 1 of the Census Bureau''s Experimental Household Pulse Survey covering April 23, 2020–July 21, 2020.Study DesignWe compare differences in health insurance coverage source and status linked to recent lob losses attributable to the COVID‐19 pandemic in states that expanded Medicaid against states that did not expand Medicaid.Data Collection/Extraction MethodsOur analytical dataset was limited to 733,181 non‐elderly adults aged 20–64.Principal FindingsTwenty‐six percent of our study sample experienced an income loss between March 13, 2020, and the time leading up to the survey—16% experienced job losses (e.g., layoff, furlough) due to the COVID‐19 crisis, and 11% had other reasons they were not working. COVID‐linked job losses were associated with a 20 (p < 0.01) percentage‐point (PPT) lower likelihood of having employer‐sponsored health insurance (ESI). Relative to persons in states that did not expand Medicaid, persons in Medicaid expansion states experiencing COVID‐linked job losses were 9 PPT (p < 0.01) more likely to report having Medicaid and 7 PPT (p < 0.01) less likely to be uninsured. The largest increases in Medicaid enrollment were among people who, based on their 2019 incomes, would not have qualified for Medicaid previously.ConclusionsOur findings suggest that expanded Medicaid eligibility may allow households to stabilize health care needs and they should become detached from private health coverage due to job loss during the pandemic. Households negatively affected by the pandemic are using Medicaid to insure themselves against the potential health risks they would incur while being unemployed.     

Medicaid Enrollment among Prison Inmates in a Non-expansion State: Exploring Predisposing,Enabling, and Need Factors Related to Enrollment Pre-incarceration and Post-Release

Prison inmates suffer from a heavy burden of physical and mental health problems and have considerable need for healthcare and coverage after prison release. The Affordable Care Act may have increased Medicaid access for some of those who need coverage in Medicaid expansion states, but inmates in non-expansion states still have high need for Medicaid coverage and face unique barriers to enrollment. We sought to explore barriers and facilitators to Medicaid enrollment among prison inmates in a non-expansion state. We conducted qualitative interviews with 20 recently hospitalized male prison inmates who had been approached by a prison social worker due to probable Medicaid eligibility, as determined by the inmates’ financial status, health, and past Medicaid enrollment. Interviews were transcribed verbatim and analyzed using a codebook with both thematic and interpretive codes. Coded interview text was then analyzed to identify predisposing, enabling, and need factors related to participants’ Medicaid enrollment prior to prison and intentions to enroll after release. Study participants’ median age, years incarcerated at the time of the interview, and projected remaining sentence length were 50, 4, and 2 years, respectively. Participants were categorized into three sub-groups based on their self-reported experience with Medicaid: (1) those who never applied for Medicaid before prison (n?=?6); (2) those who unsuccessfully attempted to enroll in Medicaid before prison (n?=?3); and (3) those who enrolled in Medicaid before prison (n?=?11). The six participants who had never applied to Medicaid before their incarceration did not hold strong attitudes about Medicaid and mostly had little need for Medicaid due to being generally healthy or having coverage available from other sources such as the Veteran’s Administration. However, one inmate who had never applied for Medicaid struggled considerably to access mental healthcare due to lapses in employer-based health coverage and attributed his incarceration to this unmet need for treatment. Three inmates with high medical need had their Medicaid applications rejected at least once pre-incarceration, resulting in periods without health coverage that led to worsening health and financial hardship for two of them. Eleven inmates with high medical need enrolled in Medicaid without difficulty prior to their incarceration, largely due to enabling factors in the form of assistance with the application by their local Department of Social Services or Social Security Administration, their mothers, medical providers, or prison personnel during a prior incarceration. Nearly all inmates acknowledged that they would need health coverage after release from prison, and more than half reported that they would need to enroll in Medicaid to gain healthcare coverage following their release. Although more population-based assessments are necessary, our findings suggest that greater assistance with Medicaid enrollment may be a key factor so that people in the criminal justice system who qualify for Medicaid—and other social safety net programs—may gain their rightful access to these benefits. Such access may benefit not only the individuals themselves but also the communities to which they return.     

Does preventive dental care reduce nonpreventive dental visits and expenditures among Medicaid‐enrolled adults?

ObjectiveTo determine whether preventive dental visits are associated with fewer subsequent nonpreventive dental visits and lower dental expenditures.Data SourcesIndiana Medicaid enrollment and claims data (2015–2018) and the Area Health Resource File.Study DesignA repeated measures design with individual and year fixed effects examining the relationship between preventive dental visits (PDVs) and nonpreventive dental visits (NPVs) and dental expenditures.Data Collection/Extraction MethodsNot applicable.Principal FindingsOf 28,152 adults (108,349 observation‐years) meeting inclusion criteria, 36.0% had a dental visit, 27.8% a PDV, and 22.1% a NPV. Compared to no PDV in the prior year, at least one was associated with fewer NPVs (β = −0.13; 95% CI –0.12, −0.11), lower NPV expenditures (β = −$29.12.53; 95% CI –28.07, −21.05), and lower total dental expenditures (−$70.12; 95% –74.92, −65.31), as well as fewer PDVs (β = −0.24; 95% CI –0.26, −0.23).ConclusionsOur findings suggest that prior year PDVs are associated with fewer subsequent NPVs and lower dental expenditures among Medicaid‐enrolled adults. Thus, from a public insurance program standpoint, supporting preventive dental care use may translate into improved population oral health outcomes and lower dental costs among certain low‐income adult populations, but barriers to consistent utilization of PDV prohibit definitive findings.     

Medicaid Policies and Practices in US State Prison Systems

Medicaid is an important source of health care coverage for prison-involved populations. From 2011 to 2012, we surveyed state prison system (SPS) policies affecting Medicaid enrollment during incarceration and upon release; 42 of 50 SPSs participated.Upon incarceration, Medicaid benefits were suspended in 9 (21.4%) SPSs and terminated in 28 (66.7%); 27 (64.3%) SPSs screened prisoners for potential Medicaid eligibility.Although many states supported Medicaid enrollment upon release, several did not. We have considered implications for Medicaid expansion.Prisoners have a heavy burden of disease.1–5 For qualifying individuals (e.g., disabled, impoverished adults with dependents and—starting in 2014 in states that choose to expand their Medicaid eligibility as part of health care reform—impoverished adults without dependents), Medicaid can provide health care coverage before and after incarceration.6 Although not assessed nationally, a study of former Texas and Ohio prisoners found that only 8% of men and 21% of women enrolled in Medicaid 8 to 10 months after release, whereas 68% and 58%, respectively, were without any health care coverage.7 Medicaid can also provide health care coverage for eligible prisoners during incarceration, when care is delivered in an inpatient setting, separate from the prison system.8Despite the role of Medicaid in financing health care for prisoners and former prisoners, the current landscape of policies and practices affecting state prisoners’ enrollment in Medicaid has not been broadly assessed. To address this gap, we conducted a survey to understand Medicaid policies and practices employed in state prison systems (SPSs).     

Insurance expansions and adolescent use of substance use disorder treatment

ObjectiveTo provide evidence on the effects of expansions to private and public insurance programs on adolescent specialty substance use disorder (SUD) treatment use.Data Source/Study SettingThe Treatment Episodes Data Set (TEDS), 1996 to 2017.Study DesignA quasi‐experimental difference‐in‐differences design using observational data.Data CollectionThe TEDS provides administrative data on admissions to specialty SUD treatment.Principal FindingsExpansions of laws that compel private insurers to cover SUD treatment services at parity with general health care increase adolescent admissions by 26% (P < .05). These increases are driven by nonintensive outpatient admissions, the most common treatment episodes, which rise by 30% (P < .05) postparity law. In contrast, increases in income eligibility for public insurance targeting those 6‐18 years old are not statistically associated with SUD treatment.ConclusionsPrivate insurance expansions allow more adolescents to receive SUD treatment, while public insurance income eligibility expansions do not appear to influence adolescent SUD treatment.     

Does Medicaid coverage of Medicare cost sharing affect physician care for dual‐eligible Medicare beneficiaries?

ObjectiveTo assess changes in physicians’ provision of care to duals (low‐income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare''s cost sharing for office visits with these patients. This policy—a provision of the Affordable Care Act—effectively increased payments for office visits with duals by 0%‐20%, depending on the state, in 2013 and 2014.Data SourcesFee‐for‐service claims for a 5% random sample of Medicare beneficiaries in 2010‐2016.Study DesignWe conducted a difference‐in‐differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)—the largest subpopulation of duals for whom payment rates were affected by this policy—to changes among other low‐income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple‐differences analysis that compared changes between QMBs and other low‐income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases.Data CollectionThe study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low‐income Medicare beneficiaries (1 914 073 beneficiary‐years from 2010 to 2016).Principal FindingsNationally, we did not find a differential increase in office visits among QMBs versus other low‐income beneficiaries that coincided with this payment change. In the triple‐differences analysis, we did not observe a greater increase in visits among QMBs vs other low‐income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple‐differences estimate: −0.12 annual visits, 95% CI: −0.28, 0.04; P = 0.15).ConclusionsPhysicians’ provision of care to low‐income Medicare beneficiaries may not be responsive to short‐run payment changes.     

Reforming Access: Trends in Medicaid Enrollment for New Medicare Beneficiaries, 2008–2011

Objective

To evaluate whether aligning the Part D low‐income subsidy and Medicaid program enrollment pathways in 2010 increased Medicaid participation among new Medicare beneficiaries.

Data Sources

Medicare enrollment records for years 2007–2011.

Study Design

We used a multinomial logistic model with state fixed effects to examine the annual change in limited and full Medicaid enrollment among new Medicare beneficiaries for 2 years before and after the reforms (2008–2011).

Data Extraction Methods

We identified new Medicare beneficiaries in the years 2008–2011 and their participation in Medicaid based on Medicare enrollment records.

Principal Findings

The percentage of beneficiaries enrolling in limited Medicaid at the start of Medicare coverage increased in 2010 by 0.3 percentage points for individuals aging into Medicare and by 1.3 percentage points for those qualifying due to disability (p < .001). There was no significant difference in the size of enrollment increases between states with and without concurrent limited Medicaid eligibility expansions.

Conclusions

Our findings suggest that streamlining financial assistance programs may improve Medicare beneficiaries’ access to benefits.     

Medicaid healthy behavior incentives and use of dental services

ObjectiveTo examine changes in access to dental care in states using Section 1115 waivers to implement healthy behavior incentive (HBI) programs in their Medicaid expansion under the ACA, compared to traditional expansion states and nonexpansion states.Data sourcesBehavioral Risk Factor Surveillance System from 2008 to 2018.Study designWe used difference‐in‐differences analysis to compare changes in three Medicaid expansion states with HBI (Iowa, Indiana, Michigan) to traditional expansion (Minnesota, North Dakota, Ohio) and nonexpansion states (Nebraska, South Dakota, Wyoming) in the same mid‐Western region of the country. The sample included 32 556 low‐income adults.Data collection/extraction methodsNA.Principal findingsWe found no significant changes in dental visits associated with HBI or traditional expansion relative to nonexpansion states. HBI expansion was associated with an increase of 2.2 percentage points in reporting a dental visit in the past year for adults in urban areas (P < 0.05) while the traditional expansion was associated with a reduction of 8.5 percentage points (P < 0.01) in utilization in rural areas relative to nonexpansion states. However, after adjustment for preexisting trends, the coefficients were no longer significant, suggesting that these differences are likely due to preexisting trends.ConclusionsWe did not find evidence of increased utilization of routine dental care associated with HBI programs.     

Do dual eligible beneficiaries experience better health care in special needs plans?

ObjectiveDual Eligible Special Needs Plans (D‐SNPs) were intended to provide better care for beneficiaries eligible for both Medicare and Medicaid through better coordination of these two programs.Data Sources671 913 dual eligible (DE) respondents to the 2009‐2019 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.Study DesignWe compared the 2015‐2019 experiences of DE beneficiaries in D‐SNPs relative to fee‐for‐service Medicare (FFS) and non‐SNP Medicare Advantage (MA) using propensity‐score weighted linear regression. Comparisons were made to 2009‐2014. 12 patient experience measures were considered.Data Collection MethodsAnnual mail survey with telephone follow‐up of non‐respondents.Principal FindingsMore than 65% of DE beneficiaries enrolled in FFS. Of 12 measures, D‐SNP performance was higher than non‐SNP MA on two (P < .05), lower than non‐SNP MA on two (P < .05), and higher than FFS on four (P < .01). DE beneficiaries did not report better coordination of care in D‐SNPs. D‐SNP performance was often worse than other coverage types in prior periods.ConclusionsRelative to FFS Medicare, DE beneficiaries report higher immunization rates in D‐SNPs, but slight or no better performance on other dimensions of patient experience. New requirements in 2021 may help D‐SNPs attain their goal of better care coordination.     

The one‐year impact of accountable care networks among Washington State employees

ObjectiveTo estimate the impact of a new, two‐sided risk model accountable care network (ACN) on Washington State employees and their families.Data Sources/Study SettingAdministrative data (January 2013‐December 2016) on Washington State employees.Study DesignWe compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0‐5, 6‐18, 19‐26, 18‐64).Data Collection/Extraction MethodsWe used difference‐in‐difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.Principal FindingsWe estimate a 1‐2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: −1.8, P < .01; age 0‐5: −1.2, P = .07; age 6‐18: −1.2, P = .06; age 19‐26; −1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19‐26 were also responsive with inpatient admissions declines (−0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.ConclusionsWashington''s state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.     

Health center use and hospital‐based care among individuals dually enrolled in Medicare and Medicaid, 2012–2018

ObjectiveTo examine the relationship between federally qualified health center (FQHC) use and hospital‐based care among individuals dually enrolled in Medicare and Medicaid.Data SourcesData were obtained from 2012 to 2018 Medicare claims.Study DesignWe modeled hospital‐based care as a function of FQHC use, person‐level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30‐day unplanned returns. We stratified all models on the basis of eligibility and rurality.Data Extraction MethodsOur sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end‐stage renal disease.Principal FindingsAfter the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person‐years among both age‐eligible (−14.8 [−17.5, −12.1]; −6.6 [−7.5, −5.6]) and disability‐eligible duals (−11.3 [−14.4, −8.3]; −6 [−7.4, −4.6]) as well as a lower probability of observation stays (−0.8 pp age‐eligible; −0.4 pp disability‐eligible) and unplanned returns (−2.1 pp age‐eligible; −1.9 pp disability‐eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person‐years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability‐eligible duals (a decrease of more than 60% compared with the pre‐PPS period) and increases in the probability of hospitalization (1.1 pp age‐eligible; 0.8 pp disability‐eligible) and ACS hospitalization (0.5 pp age‐eligible; 0.3 pp disability‐eligible) (a decrease of roughly 50% compared with the pre‐PPS period).ConclusionsFQHC use is associated with reductions in hospital‐based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.     

Health insurance coverage and self‐employment

BackgroundSelf‐employed workers are 10% of the US labor force, with growth projected over the next decade. Whether existing policy mechanisms are sufficient to ensure health insurance coverage for self‐employed workers, who do not have access to employer‐sponsored coverage, is unclear.ObjectiveTo determine whether self‐employment is associated with lack of health insurance coverage.Data SourcesSecondary analysis of Medical Expenditure Panel Survey (MEPS) data collected 2014‐2017.Study DesignParticipants were working age (18‐64 years), employed, civilian noninstitutionalized US adults with two years of Medical Expenditure Panel Survey (MEPS) participation in 2014‐2017. We compared those who were employees vs those who were self‐employed. Key outcomes were self‐report of health insurance coverage, and of delaying needed medical care.Data Extraction MethodsLongitudinal design among individuals who were employees during study year 1, comparing health insurance coverage among those who did vs did not transition to self‐employment in year 2.Principal Findings16 335 individuals, representing 121 473 345 working‐age adults, met inclusion criteria; of these, 147, representing 1 097 582 individuals, transitioned to self‐employment. In unadjusted analyses, 25.7% of those who became self‐employed were uninsured in year 2, vs 8.1% of those who remained employees (P < .0001). In adjusted models, self‐employment was associated with greater risk of being uninsured (26.1% vs 8.0%, risk difference 18.0%, 95% confidence interval [CI] 9.2% to 26.9%, P = .0001). A time‐by‐employment type product term suggests that 10.0 percentage points (95%CI 0.3 to 19.7 percentage points, P = .04) of the risk difference may be attributable to the change to self‐employment. Self‐employment was also associated with delaying needed medical care (12.0% vs 3.1%, risk difference: 8.9%, 95% CI 3.1% to 14.6%, P = .003).ConclusionsOne in four self‐employed workers lack health insurance coverage. Given the rise in self‐employment, it is imperative to identify ways to improve health care insurance access for self‐employed working‐age US adults.