How Health Insurance Instability Differentially Impedes Access to Sexual and Reproductive Healthcare, by Race/Ethnicity and Nativity

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OBJECTIVE: To document differential risk of insurance instability by race/ethnicity and nativity and investigate the effect of insurance instability on subsequent sexual and reproductive health care utilization and contraceptive access. STUDY SETTING AND DESIGN: We draw on data from the Surveys of Women (SoW), longitudinal household surveys conducted by NORC at the University of Chicago in Arizona, Iowa, New Jersey, and Wisconsin, weighted to reflect the population of women aged 18-44 in each state. SoW respondents included in this analysis were interviewed 2-4 times between 2018 and 2022 about their sexual and reproductive health-related experiences. We use race-stratified population averaged logistic regressions to model the risk of insurance churn and insurance loss for US-born vs. foreign-born people with the capacity for pregnancy, by race/ethnicity. Then, we use within-between (hybrid) logistic regressions to model the effect of insurance instability on subsequent sexual and reproductive health care utilization and contraceptive access outcomes, including receipt of any sexual and reproductive health care, receipt of contraceptive care, experiencing barriers to obtaining contraception, and contraceptive use. DATA SOURCES AND ANALYTIC SAMPLE: Our analytic sample includes 12,208 observations from 4558 respondents between the ages of 18 and 44 who were assumed to have the capacity for pregnancy. Respondents were maintained in the sample if they were neither pregnant nor infertile and had non-missing information on key variables. PRINCIPAL FINDINGS: Insurance loss was much more common among foreign-born compared to US-born people, particularly those who were racially or ethnically minoritized, with foreign-born BIPOC and foreign-born Hispanic respondents experiencing insurance loss 2.5 and 3 times as often as their US-born counterparts, respectively. Meanwhile, findings from our hybrid models suggest that losing insurance was associated with a five percentage point reduction in the probability of subsequent utilization of sexual and reproductive health care (∆p = -0.046, p < 0.05, SE = -0.02) and a five percentage point increase in the probability of experiencing subsequent barriers to obtaining preferred contraception (∆p = 0.053, p < 0.001, SE = 0.01). CONCLUSION: The disproportionate burden of insurance instability among immigrant people of color may exacerbate barriers to sexual and reproductive health care and contraceptive access for a population that already experiences high barriers to obtaining this care relative to non-Hispanic White people.

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