Public Health in the Rockies 2026

Background: The COVID-19 pandemic triggered unprecedented job losses, placing millions of working-age Americans at risk of losing employer-sponsored insurance (ESI). Despite growing evidence of overall coverage disruptions, little is known about how losses and recovery varied simultaneously by gender, race/ethnicity, marital status, education, and income using a comprehensive intersectional framework extending through 2024. This study addresses that gap by examining how ten distinct insurance coverage types changed across demographic groups during and after the pandemic.

Methods: This study uses American Community Survey (ACS) 1-year samples from IPUMS covering 2020–2024, providing nationally representative data on adults aged 18–64 (n=9,407,269). Ten insurance outcomes are examined: any coverage (HCOVANY), private coverage (HCOVPRIV), employer-sponsored (HINSEMP), direct purchase (HINSPUR), TRICARE (HINSTRI), any public coverage (HCOVPUB), Medicaid (HINSCAID), Medicare (HINSCARE), VA (HINSVA), and Indian Health Service (HINSIHS). Analyses include survey-weighted descriptive statistics, logistic regression, interaction models testing whether sex effects differ by race/ethnicity, age group, and income, and difference-in-differences models comparing expansion versus non-expansion states. All analyses apply person-level survey weights for nationally representative estimates.

Results: Overall, uninsurance declined from 13.2% in 2020 to 11.3% in 2023 but rebounded to 11.6% in 2024, likely reflecting Medicaid unwinding. Women were consistently 35% less likely to be uninsured than men. Black and American Indian and Alaska Native women showed the highest Medicaid dependence and largest gender gaps in uninsurance. The female ESI advantage grew significantly with income while the Medicaid advantage weakened at higher income levels.

Implications: Coverage inequities by gender, race/ethnicity, and income persisted throughout the pandemic and recovery without closing. Public health professionals should advocate for policies that strengthen Medicaid, expand outreach to vulnerable populations, and decouple health insurance from employment to advance equitable access to care across Colorado and the nation.