New evidence shows COVID-19 isn’t done with us yet

The pandemic continues to have negative long-term public health consequences, with preventative health screenings and wellness visits showing the biggest declines, new evidence suggests.

In an original investigation published last Friday in JAMA Health Forum, investigators at Harvard-affiliated Beth Israel Deaconess Medical Center evaluated changes in healthcare access and preventative screenings among U.S. adults between 2019 and 2022. The researchers observed that in 2021, there were fewer outpatient wellness visits and that screening rates for blood pressure, cholesterol, blood sugar, and common cancers were lower than before the pandemic. The scientists also showed that access to these services varied across racial and ethnic groups.

“Our finding that preventative health screenings did not return back to pre-pandemic levels has critically important public health implications,” said corresponding author Rishi K. Wadhera, section head of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology at BIDMC, who is also an associate professor of medicine at Harvard Medical School. “The consequences of disruptions in preventive health screenings during the pandemic could be devastating over the long term, especially if those patterns continue to persist through today.”

Using deidentified data from more than 90,000 respondents to a national health survey, Wadhera and colleagues evaluated access to regular and preventative healthcare and assessed whether race and ethnicity and/or socioeconomic factors played a role. While there was no change in having a usual place for care in 2019 versus 2021, having a wellness visit in the past year was less common in 2021 for all adults, with the decline most pronounced for Asian adults. White, Black, and Hispanic adults’ likelihood of having a wellness visit rebounded in 2022, but remained below pre-pandemic levels for Asian adults.

The proportions of adults who received screenings for cardiovascular disease, blood glucose levels, and cervical, breast, and prostate cancer were lower overall in 2021 versus 2019, with Asian adults experiencing the steepest declines. For colorectal cancer screening, Black and white adults had the steepest declines.

The investigators showed that these declines were not due to disruptions in insurance coverage during the pandemic; fewer adults overall reported delaying medical care and not receiving care due to costs in 2022 than in 2019. This finding may have been due to federal and state governments bolstering safety-net protections, including expanding Medicaid coverage through a continuous enrollment provision in response to the COVID-19 pandemic in 2020, which mitigated loss of coverage. The Medicaid continuous enrollment provision ended in 2023, and an estimated 16 million adults have since been disenrolled from Medicaid.

“Heart disease and cancer are leading causes of death in the U.S., and persistently lower rates of routine screenings could have potentially major consequences for morbidity and mortality long-term, particularly in light of rising cardiometabolic disease rates in young adults,” said first author Chris Alba, a medical student at Harvard and research fellow at the Smith Center. “Racial and ethnic minority populations received the fewest preventative screenings in 2019, and a slower recovery from pandemic-related disruptions in these services may worsen health care disparities in future years. These findings highlight the urgent need for concerted health system, public health, and health policy efforts to increase preventative screenings among all eligible U.S. adults.”

In an analysis of the same data set published in the Annals of Internal Medicine, Wadhera and colleagues examined how the pandemic impacted food insecurity among low-income households. The team showed that food insecurity decreased from 21 percent in 2019 to 16 percent in 2021, but returned back to pre-pandemic levels in 2022.

Among the subset of low-income people receiving federal nutritional benefits as part of the Supplemental Nutritional Assistance Program (SNAP), food insecurity decreased significantly from 35 percent in 2019 to 22 percent in 2021, and remained lower in 2022. That’s due to historic increases in SNAP benefits enacted in response to the COVID-19 pandemic, which are now expiring on a state-by-state basis.

“Despite worsening unemployment and economic loss caused by the pandemic, food insecurity decreased in 2021 among low-income adults, highlighting the importance of unprecedented increases in nutritional benefits through the SNAP program during the pandemic,” said Wadhera. “Our findings provide important insights as Congress debates the upcoming farm bill, which will determine the U.S. nutritional policy for the next five years.”

“Changes in Health Care Access and Preventative Health Screenings by Race and Ethnicity”: Co-authors included Christopher Alba of Harvard Medical School and ZhaoNian Zheng of BIDMC.

“Food Insecurity Among Low-Income U.S. Adults During the COVID-19 Pandemic”: Co-authors included Aaron L. Troy, Isabella Ahmad, and ZhaoNian Zheng of BIDMC.

This research was funded by the National Heart, Lung and Blood Institute (grants R01HL164561 and K23HL148525). Wadhera reported receiving grants from the National Heart, Lung and Blood Institute during the conduct of this study and personal fees from Chambercardio and Abbott outside the submitted work. No other disclosures were reported.