Doctor Visits Dipped During COVID-19, Especially for Low-Income Americans

Utilization of ambulatory care services declined during the COVID-19 pandemic, especially among socioeconomically disadvantaged Americans.

Americans were initially advised to avoid non-essential healthcare visits during the COVID-19 pandemic, leading to a dip in outpatient health services at the beginning of 2020. Health visits rebounded to normal levels by the end of 2020, dipping again during the second wave in January and February 2021.

However, one study, published in the Journal of the American Medical Association, found that the 2020 return to in-person health services was far less likely among socioeconomically disadvantaged people.

The retrospective cohort study was led by UCLA Health Sciences, and examined socioeconomic differences in returning to ambulatory care. The study included over 14.5 million patients who utilized ambulatory care services from January 1, 2019-February 28, 2021. The average age of the included US adults was 52.7 years, and 54.9% of the cohort was female.

Using a difference-in-differences design, investigators estimated the extent to which healthcare services during the pandemic differed from expected rates. The investigators measured the utilization rates per 100 patients of 6 ambulatory services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. They used Poisson regression models adjusted for age, sex, total patient-months, and insurance and service type.

From March-April 2020, the combined use of the 6 healthcare services decreased to 67% of expected rates, but returned to 96.7% of expected rates by November-December 2020. During the second wave of COVID-19 infections in January-February 2021, ambulatory service utilization declined to 86.2% of expected rates, though colonoscopies and mammograms were lower, at 65% and 79.2%, respectively.

By January-February 2021, return to expected rates of healthcare utilization by type of insurance were: patients with Medicaid at 78.4%, Medicare-Medicaid dual eligibility at 73.3%, commercial at 90.7%, Medicare Advantage at 83.2%, and Medicare fee-for-service at 82.0%.

The aggregate use of 6 ambulatory care services gradually rebounded after the onset of the COVID-19 pandemic. However, the return to these healthcare services was significantly lower for patients with Medicaid or Medicare-Medicaid dual eligibility than for those with commercial, Medicare Advantage, or Medicare fee-for-service insurance.

“The worsening access to care we observed among socioeconomically disadvantaged Americans is particularly concerning because it suggests that the pandemic is widening inequities in access to vital health services such as emergency care, preventive cancer screening and behavioral health services,” said Dr. John Mafi, the study’s lead author and an associate professor of medicine and practicing general internist at the David Geffen School of Medicine at UCLA.