{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T05:09:26Z","timestamp":1789016966706,"version":"build-2803163510"},"reference-count":24,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To examine whether health insurance coverage-gap duration predicts subsequent cost-related barriers to care among working-age adults with multimorbidity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We pooled Medical Expenditure Panel Survey Panels 23 and 24, identifying 1,694 adults aged 18\u201364\u202fyears with at least two of nine chronic physical condition groups at baseline. Uninsured months during Years 1\u20132 were categorized as 0, 1\u20135, 6\u201323, or 24. The outcome was any cost-related delay in or inability to obtain medical care or prescription medicines during Years 3\u20134. Survey-weighted logistic regression accounted for weights, strata, primary sampling units, domain analysis, and Taylor-series linearization. Sensitivity analyses examined categorical age, insurance-source patterns, and cancer exclusion. Constant 2022\u202fUS-dollar expenditures were summarized using weighted medians and interquartile ranges and analyzed using two-part models with survey-aware jackknife confidence intervals for standardized means.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 1,694 participants, 379 experienced the outcome. Compared with no gap, adjusted odds ratios were 1.61 (95% CI, 0.94\u20132.77) for 1\u20135 uninsured months, 2.06 (95% CI, 1.17\u20133.63) for 6\u201323\u202fmonths, and 3.44 (95% CI, 1.84\u20136.44) for 24\u202fmonths; adjusted probabilities were 17.4, 24.8, 29.3, and 39.8%, respectively. Findings were robust to categorical age adjustment and cancer exclusion. Only continuous uninsurance was significantly associated with the outcome relative to continuous private coverage. For continuous uninsurance versus no gap, weighted median total expenditures were $1,235 versus $9,378, and median out-of-pocket expenditures were $464 versus $944. Adjusted total expenditures were lower ($4,884 vs. $26,134; ratio, 0.19;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001), whereas adjusted out-of-pocket expenditures did not differ significantly ($2,632 vs. $2,229; ratio, 1.18;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.422).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Longer coverage gaps were associated with greater subsequent cost-related barriers. Lower total spending without significantly lower out-of-pocket spending among continuously uninsured adults suggests foregone or reduced care rather than improved financial protection.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1965839","type":"journal-article","created":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T04:30:57Z","timestamp":1789014657000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Duration of health insurance coverage gaps and subsequent cost-related barriers to care among adults aged 18\u201364\u202fyears with multimorbidity"],"prefix":"10.3389","volume":"14","author":[{"given":"Yongwen","family":"Cao","sequence":"first","affiliation":[{"name":"School of Public Health, Lanzhou University","place":["Lanzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhendong","family":"Liu","sequence":"additional","affiliation":[{"name":"Gansu University of Chinese Medicine","place":["Lanzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Minmin","family":"Jiang","sequence":"additional","affiliation":[{"name":"Gansu Provincial Hospital","place":["Lanzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tingting","family":"Ge","sequence":"additional","affiliation":[{"name":"Gansu Provincial Maternal and Child Health Hospital (Gansu Central Hospital)","place":["Lanzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lu","family":"Zhang","sequence":"additional","affiliation":[{"name":"Gansu Provincial Maternal and Child Health Hospital (Gansu Central Hospital)","place":["Lanzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yixi","family":"Liu","sequence":"additional","affiliation":[{"name":"Gansu Provincial Maternal and Child Health Hospital (Gansu Central Hospital)","place":["Lanzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiuxia","family":"Li","sequence":"additional","affiliation":[{"name":"School of Public Health, Lanzhou University","place":["Lanzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,10]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"E66","DOI":"10.5888\/pcd10.120239","article-title":"Defining and measuring chronic conditions: imperatives for research, policy, program, and practice","volume":"10","author":"Goodman","year":"2013","journal-title":"Prev Chronic Dis"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"503","DOI":"10.3122\/jabfm.2018.04.180008","article-title":"Multimorbidity trends in United States adults, 1988\u20132014","volume":"31","author":"King","year":"2018","journal-title":"J Am Board Fam Med"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"E106","DOI":"10.5888\/pcd17.200130","article-title":"Prevalence of multiple chronic conditions among US adults, 2018","volume":"17","author":"Boersma","year":"2020","journal-title":"Prev Chronic Dis"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"1083","DOI":"10.1016\/j.amjmed.2022.04.010","article-title":"Temporal trends in racial and ethnic disparities in multimorbidity prevalence in the United States, 1999-2018","volume":"135","author":"Caraballo","year":"2022","journal-title":"Am J Med"},{"key":"ref5","volume-title":"Out-of-Pocket Expenditures for Adults with Health Care Expenses for Multiple Chronic Conditions, US Civilian Noninstitutionalized Population, 2014","author":"Soni","year":"2017"},{"key":"ref6","volume-title":"Health Insurance Continuity and Health care Access and Utilization, 2014","author":"Villarroel","year":"2016"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1494","DOI":"10.1007\/s11606-019-05002-w","article-title":"Prevalence and correlates of medical financial hardship in the USA","volume":"34","author":"Yabroff","year":"2019","journal-title":"J Gen Intern Med"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"334","DOI":"10.1186\/s12913-020-05226-1","article-title":"Insurance patterns and instability from 2006 to 2016","volume":"20","author":"Gai","year":"2020","journal-title":"BMC Health Serv Res"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"e006139","DOI":"10.1161\/CIRCOUTCOMES.119.006139","article-title":"Burden and consequences of financial hardship from medical bills among nonelderly adults with diabetes mellitus in the United States","volume":"13","author":"Caraballo","year":"2020","journal-title":"Circ Cardiovasc Qual Outcomes"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"107248","DOI":"10.1016\/j.ypmed.2022.107248","article-title":"Disease and debt: findings from the 2019 panel study of income dynamics in the United States","volume":"164","author":"Grafova","year":"2022","journal-title":"Prev Med"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"E151","DOI":"10.5888\/pcd17.200244","article-title":"Cost-related nonadherence and mortality in patients with chronic disease: a multiyear investigation, National Health Interview Survey, 2000\u20132014","volume":"17","author":"Van Alsten","year":"2020","journal-title":"Prev Chronic Dis"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"662","DOI":"10.18553\/jmcp.2025.31.7.662","article-title":"Changes in cost-related nonadherence among US adults with multiple chronic conditions from 2019 to 2023","volume":"31","author":"Amill-Rosario","year":"2025","journal-title":"J Manag Care Spec Pharm"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"483","DOI":"10.1097\/MLR.0000000000000509","article-title":"Does churning in Medicaid affect health care use?","volume":"54","author":"Roberts","year":"2016","journal-title":"Med Care"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"e0238100","DOI":"10.1371\/journal.pone.0238100","article-title":"Insurance instability and use of emergency and office-based care after gaining coverage: an observational cohort study","volume":"15","author":"Shafer","year":"2020","journal-title":"PLoS One"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"443","DOI":"10.1111\/j.1468-0009.2009.00564.x","article-title":"Health consequences of uninsurance among adults in the United States: recent evidence and implications","volume":"87","author":"McWilliams","year":"2009","journal-title":"Milbank Q"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"3S","DOI":"10.1177\/1077558703254101","article-title":"Sicker and poorer\u2014the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income","volume":"60","author":"Hadley","year":"2003","journal-title":"Med Care Res Rev"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"1713","DOI":"10.1056\/NEJMsa1212321","article-title":"The Oregon experiment\u2014effects of Medicaid on clinical outcomes","volume":"368","author":"Baicker","year":"2013","journal-title":"N Engl J Med"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"2373","DOI":"10.1007\/s11606-021-07100-0","article-title":"Preventing financial strain for low-and moderate-income adults: a comparison of Medicaid, marketplace, and employer-sponsored insurance","volume":"37","author":"Saluja","year":"2022","journal-title":"J Gen Intern Med"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"e242193","DOI":"10.1001\/jamahealthforum.2024.2193","article-title":"Coverage and access changes during Medicaid unwinding","volume":"5","author":"McIntyre","year":"2024","journal-title":"JAMA Health Forum"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"700","DOI":"10.1377\/hlthaff.2013.1023","article-title":"Medicaid and marketplace eligibility changes will occur often in all states; policy options can ease impact","volume":"33","author":"Sommers","year":"2014","journal-title":"Health Aff"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"1518","DOI":"10.1377\/hlthaff.2024.00641","article-title":"Resumption of Medicaid eligibility redeterminations: little change in overall insurance coverage","volume":"43","author":"Gupta","year":"2024","journal-title":"Health Aff"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1377\/hlthaff.2019.00378","article-title":"Among low-income adults enrolled in Medicaid, churning decreased after the affordable care act: this study examines whether the affordable care act\u2019s expansion of Medicaid eligibility had an impact on coverage disruptions\u2013known as \u201cchurning\u201d\u2013among Medicaid enrollees","volume":"39","author":"Goldman","year":"2020","journal-title":"Health Aff"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"795","DOI":"10.7326\/M15-2234","article-title":"Early coverage, access, utilization, and health effects associated with the affordable care act Medicaid expansions: a quasi-experimental study","volume":"164","author":"Wherry","year":"2016","journal-title":"Ann Intern Med"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"1119","DOI":"10.1377\/hlthaff.2017.0293","article-title":"Three-year impacts of the affordable care act: improved medical care and health among low-income adults","volume":"36","author":"Sommers","year":"2017","journal-title":"Health Aff"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1965839\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T04:31:09Z","timestamp":1789014669000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1965839\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,10]]},"references-count":24,"alternative-id":["10.3389\/fpubh.2026.1965839"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1965839","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,10]]},"article-number":"1965839"}}