Insurance Type and Menopausal Hormone Therapy Use Among US Women

Importance: Access to menopausal hormone therapy (MHT) in the US remains low. Understanding whether insurance type is associated with MHT underuse and racial disparities in menopausal care is critical for designing interventions that increase evidence-based and equitable menopause care. Objective: To examine whether Medicaid compared with private insurance is associated with lower MHT use among US women. A secondary objective explored the degree that payer type is associated with observed racial differences in MHT use. Design, Setting, and Participants: This cross-sectional study used the 2013-2014, 2015-2016, and 2017-2020 cycles of the National Health and Nutrition Examination Survey (NHANES) to identify a survey-weighted analytic subset of eligible respondents of a population-based survey of the US civilian, noninstitutionalized population. The study included women aged 45 to 64 years with Medicaid or private insurance coverage who were eligible for MHT. Statistical analyses were performed between March 26, 2024, and December 2, 2025. Exposure: Insurance type. Main Outcomes and Measures: MHT use was the primary outcome. A secondary analysis assessed whether insurance status was associated with observed racial differences in MHT use. Associations were estimated using multivariable logistic regression. Results: The unweighted sample included 1666 National Health and Nutrition Examination Survey respondents (n = 22 275 545, weighted). Of the weighted final sample, 91.4% had private insurance, and 8.6% had Medicaid. Individuals insured by Medicaid were less likely than those with private insurance to report a history of MHT use (10.7% [95% CI, 6.9%-16.0%] vs 20.7% [95% CI, 18.1%-23.5%]). After adjustment, Medicaid-insured women had lower odds of MHT use than privately insured women (OR, 0.50 [95% CI, 0.28-0.87]). In a secondary analysis, Black participants showed lower odds of MHT than White participants (OR, 0.68 [95% CI, 0.45-0.95]), but this difference was attenuated once insurance status was included in the model (adjusted OR, 0.72 [95% CI, 0.50-1.04]). Conclusions and Relevance: In this cross-sectional study of women at typical age for menopause, Medicaid coverage was associated with significantly lower MHT use, suggesting that insurance type may play a role in menopausal care disparities. Insurance status may also partially explain previously observed racial gaps in MHT use. These findings highlight the need for policy and clinical interventions to address insurance-related barriers and to promote equitable menopausal care.