For Many, Health Insurance Another Likely Casualty of COVID-19

The coronavirus pandemic could leave many without health insurance and worsen already stark racial and ethnic divides in health care, experts warn.

Not having health insurance can mean delaying or totally forgoing medical care – a major concern during a global public health crisis in which timely access to care is critical for both the health of individuals and that of communities overall. And although experts are alarmed that widespread job losses during the pandemic will leave millions of people without coverage, some groups have seen stubbornly high uninsured rates for years.

According to the most recent data available from a federal survey, 13.7% of adults 18 to 64 years old, or 27.2 million people, were uninsured in the first half of 2019 – up from 13.3% in 2018. Racial disparities were apparent: 27.2% of Hispanic adults were uninsured, as were 13.6% of black adults, 7.4% of Asians and 9.8% of whites. Among adults of multiple races or a race other than Asian, black or white, the uninsured rate was 23%.

Those disparities are longstanding and largely remained in place this spring, according to an ongoing survey led by the U.S. Census Bureau that aims to track the pandemic's impact on employment, housing, health and more. Early data from the survey indicates persistent gaps in coverage between whites and blacks and whites and Hispanics in particular.

"The same groups that have been the most vulnerable in this pandemic are also most likely to be uninsured, even before the pandemic," says Sara Collins, vice president for health care coverage and access at The Commonwealth Fund.

The vast majority of Americans get their health insurance through work, and unemployment rates tend to be higher among Hispanic and black Americans compared with whites and Asians, despite similar levels of labor force participation across races and ethnicities. People of color also are overrepresented in the service industry and are less likely to have health insurance through their employers.

Other factors play a role in health coverage disparities, too: While the Affordable Care Act helped narrow insurance gaps, states that have opted not to expand Medicaid coverage to more low-income residents tend to have higher shares of black residents. That means people who lose their jobs and health coverage there during the pandemic may also be less likely to gain insurance through the public program, says Lynn Blewett, director of the State Health Access Data Assistance Center and a professor in the School of Public Health at the University of Minnesota.

Immigrants also have faced hurdles to health coverage. The Trump administration's public charge rule, which expanded the government's ability to deny immigrants legal residence in the U.S. based on their past use of public benefits, went into effect in February. Even before then, it had a major chilling effect on enrollment in programs like Medicaid, an Urban Institute analysis found.

Now, the pandemic's "economic impact is having a greater impact on those with lower incomes and for populations of color," Blewett says, in turn posing greater risk to people in those communities of losing insurance coverage, even as many face greater health risks tied to COVID-19.

Although data remains limited months into the pandemic, the coronavirus' unequal toll on black, Hispanic and low-income communities has become clear. For example, as of mid-April, counties with an above-average share of black residents made up 22% of all U.S. counties, but had 52% of all COVID-19 cases and 58% of deaths, according to a study by amfAR, The Foundation for AIDS Research. The analysis also tied nearly 127,000 "excess diagnoses" of the coronavirus to a lack of health insurance.

Yet lingering issues with data and testing may mask the true toll of COVID-19 in communities of color. While most states are reporting confirmed cases and deaths by race and ethnicity, just four are reporting testing data along those lines, according to a Johns Hopkins University tracker. In Los Angeles, meanwhile, recent testing criteria left some infected people unable to get tested and subsequently included in official case counts for some time, if at all, says David Hayes-Bautista, who established the Center for the Study of Latino Health and Culture at UCLA.

"It's still hard to get a test," Hayes-Bautista says. "Now what we're seeing is Latinos entering the data systems way after they should've been tested, way after they should've gotten some primary care, and still being overexposed."

The pandemic has already affected access to health care access more broadly. More than 40% of U.S. adults late last month said they delayed or did not get the health care they needed recently, the recent Census Bureau survey shows. As of late April, more than 10 million adults had lost their health insurance during the pandemic, either because they lost their jobs or canceled their coverage due to cost, according to a University of Minnesota survey.

People who lose their jobs and health coverage can sign up for insurance during a special enrollment period through state and federal marketplaces and may be eligible for subsidies to help them pay. Others may be eligible for Medicaid, the public health insurance program. But if they don't realize that, they may "go without insurance unnecessarily," Collins says.

For those who already lacked insurance, additional people losing it could lead to a strain on safety net resources for the uninsured, such as community health centers – some of which already are struggling to stay afloat during the pandemic. And with unemployment rates up and state revenues down, multiple states have weighed cuts to their Medicaid programs.

"We have a combination of a very serious public health crisis and we have a very, very serious economic crisis," Collins says. "It's a lethal combination."