Assessing Shifts in Health Disparities: Analyzing the Impact of the COVID-19 Pandemic in Washington State, 2018-2023

Background: The COVID-19 pandemic intensified longstanding health inequities in the United States, particularly among historically marginalized racial and ethnic groups. In Washington State, American Indian/Alaska Native (AIAN), Native Hawaiian/Pacific Islander (NHPI), Black, and Hispanic populations face disproportionate burdens due to structural determinants such as socioeconomic disadvantage, limited healthcare access, and systemic racism. However, limited research has examined how these disparities evolved across different phases of the pandemic at the state level. Methods: This retrospective observational study analyzed data from the Washington State Behavioral Risk Factor Surveillance System (BRFSS), spanning 2018–2023 (n = 100,791 after applying exclusion criteria). Key outcomes included frequent poor mental health (defined as ≥14 days of poor mental health in the past 30 days), chronic disease (a composite indicator of any of the following self-reported, physician-diagnosed conditions: asthma (current), diabetes, arthritis, chronic obstructive pulmonary disease (COPD), kidney disease, stroke, myocardial infarction, and angina or coronary heart disease (CHD)), and healthcare access (defined as being unable to see a doctor due to cost). Survey-weighted logistic and Poisson regression models estimated adjusted prevalence differences (PDs) and prevalence ratios (PRs) across three pandemic periods—pre-pandemic (2018–2019), during-pandemic (2020–2021), and post-pandemic (2022–2023)—by race/ethnicity, adjusting for age, sex, education, and employment. Results: Racial and ethnic disparities in mental health, chronic disease, and healthcare access (i.e., being unable to see a doctor due to cost) widened during and after the COVID-19 pandemic in Washington State. Asian and Hispanic adults consistently reported lower adjusted prevalence and prevalence ratios (PRs) of frequent poor mental health compared to White adults, including during the post-pandemic period (Asian: PR = 0.72; 95% Confidence Interval (CI): 0.55–0.94; Hispanic: PR = 0.68; 95% CI: 0.55–0.83). In contrast, American Indian/Alaska Native (AIAN) and Native Hawaiian/Pacific Islander (NHPI) adults experienced the highest burden of chronic disease post-pandemic, with adjusted prevalence exceeding that of White adults by 15.3 and 16.7 percentage points, respectively. PRs for chronic disease remained significantly elevated for both groups (AIAN: 1.34; 95% CI: 1.11–1.62; NHPI: 1.44; 95% CI: 1.08–1.91). Cost-related barriers to care were disproportionately high among AIAN, NHPI, and Hispanic adults. Post-pandemic PRs were 1.86 (95% CI: 1.13–3.06) for AIAN adults, 1.71 (95% CI: 1.40–2.07) for Hispanic adults, and 1.93 (95% CI: 1.12–3.35) for NHPI adults, compared to White adults. Conclusions: Racial and ethnic health disparities persisted and, in many cases, worsened during and after the COVID-19 pandemic. AIAN and NHPI adults experienced the highest burden of chronic disease and mental health challenges, while Hispanic adults faced rising financial barriers to care. These patterns reflect longstanding structural inequities and highlight the urgent need for sustained, equity-focused public health investments, including culturally responsive services, expanded access to care, and long-term support for historically underserved communities.