Intersecting U.S. Epidemics: COVID-19 and Lack of Health Insurance
Authors: Steffie Woolhandler, David U. Himmelstein
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions7 April 2020Intersecting U.S. Epidemics: COVID-19 and Lack of Health InsuranceFREESteffie Woolhandler, MD, MPH and David U. Himmelstein, MDSteffie Woolhandler, MD, MPHCity University of New York at Hunter College, New York, New York, and Harvard Medical School and Cambridge Health Alliance, Cambridge, Massachusetts (S.W., D.U.H.) and David U. Himmelstein, MDCity University of New York at Hunter College, New York, New York, and Harvard Medical School and Cambridge Health Alliance, Cambridge, Massachusetts (S.W., D.U.H.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-1491 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail During the final week of March 2020, the U.S. Department of Labor reported that a record number of workers—6.648 million—filed new claims for unemployment benefits. That beat the previous record of 3.307 million filings, which was set the week before, bringing the 2-week total to 9.955 million. This is just the beginning of the surge in joblessness due to the coronavirus disease 2019 (COVID-19) pandemic. A Federal Reserve Bank economist estimated that the ranks of unemployed persons will swell by 47.05 million by the end of June (1).For many, job loss will carry the added sting of losing health insurance. Congress has moved to cover severe acute respiratory syndrome coronavirus 2 testing for uninsured persons, but did not include provisions to cover treatment of COVID-19 (or other illnesses). The recent $2 trillion bailout bill offered no new health insurance subsidies or coverage.Estimating Coverage LossesWe estimated the likely effects of current job losses on the number of uninsured persons by using data from the U.S. Census Bureau's March 2019 Current Population Survey on health insurance coverage rates among persons who lost or left a job. The uninsurance rate among unemployed persons who had lost or left a job was 26.3% versus 10.7% among those with jobs. Applying the 15.6–percentage point difference to the 9.955 million who filed new unemployment claims last week, we estimate that 1.553 million newly unemployed persons will lose health coverage. This figure excludes family members who will become uninsured because a breadwinner lost coverage and self-employed persons who may lose coverage because their businesses were shuttered, but are ineligible for unemployment benefits. If, as the Federal Reserve economist projects, an additional 47.05 million people become unemployed, 7.3 million workers (along with several million family members) are likely to join the ranks of the U.S. uninsured population.Coverage losses are likely to be steepest in states that have turned down the Patient Protection and Affordable Care Act's Medicaid expansion. In expansion states, the share of persons who have lost or left a job who lacked coverage was 22.1% versus 8.3% for employed persons—a difference of 13.8 percentage points. In nonexpansion states, the uninsurance rate among such unemployed persons was 38.4% versus 15.8% for employed persons—a difference of 22.6 percentage points. In other words, nearly 1 in 4 newly unemployed workers in nonexpansion states are likely to lose coverage, bringing their overall uninsurance rate to nearly 40%.Our projections are based on differences in coverage rates for employed and unemployed persons in 2019, but there is little reason to believe that the predicament of unemployed workers has improved since then. Although many who lose their jobs are likely to be eligible for Medicaid or subsidized Affordable Care Act coverage, and some will purchase continuing coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act), the same was true in 2019. Indeed, the situation may be worse today because some laid-off workers probably gained coverage through an employed spouse in 2019, an option less likely to be available in the face of the impending massive layoffs.Urgent Policy Needs and Longer-Term SolutionsWith jobs and health insurance coverage disappearing as the COVID-19 pandemic rages, states that have declined to expand Medicaid should urgently reconsider. Yet, the high uninsurance rate among unemployed persons in Medicaid expansion states underlines the need for action in Washington. Tax revenues are plunging, and all states except Vermont are required to balance their budgets annually. Hence, only the federal government has the wherewithal to address the impending crisis.Thus far, neither Congress nor the administration has offered plans to expand coverage. Some have suggested that the federal government cover COVID-19–related care for uninsured persons through Medicaid (2), but some states would probably decline such a Medicaid expansion, leaving many newly jobless persons—and the 28 million who were uninsured before the pandemic—without coverage. Instead, we advocate for passage of an emergency measure authorizing Medicare coverage for all persons eligible for unemployment benefits.Although the COVID-19 crisis demands urgent action, it also exposes the imprudence of tying health insurance to employment, and the need for more thoroughgoing reform. A trickle of families facing the dual disaster of job loss and health insurance loss can remain under Washington's radar. However, the current tsunami of job and coverage losses along with a heightened risk for severe illness demands action. A decade ago, Victor Fuchs (3) forecasted that "National health insurance will probably come to the United States after a major change in the political climate—the kind of change that often accompanies a war, a depression, or large-scale civil unrest." Such a major change may be upon us.References1. Faria e Castro M. Back-of-the-envelope estimates of next quarter's unemployment rate. Accessed at www.stlouisfed.org/on-the-economy/2020/march/back-envelope-estimates-next-quarters-unemployment-rate on 2 April 2020. Google Scholar2. Glied S, Swartz K. Using federal reinsurance to address the health care financial consequences of COVID-19. Accessed at www.healthaffairs.org/do/10.1377/hblog20200401.505998/full on 2 April 2020. Google Scholar3. Fuchs VR. What's ahead for health insurance in the United States? N Engl J Med. 2002;346:1822-4. [PMID: 12050346] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Steffie Woolhandler, David HimmelsteinCity University of New York at Hunter College and Harvard Medical School10 April 2020 Updated Uninsured Estimates as of 4/10/20 We have updated the estimates presented above to reflect unemployment filings in early April, as well as loss of coverage among dependents of breadwinners filing for unemployment. According to the Census Bureau survey, on average, for every 100 workers with employed-paid coverage, 83.7 dependents are covered under the worker's policy.As of 4/10, we estimate that 4,805,894 US workers and their dependents have lost health insurance coverage since mid March. We estimate that a total of 13.475 million will join the ranks of the uninsured by June 30. James R. Webster MD, MS, MACPProf. Emeritus,:Department of Medicine, Feinberg School of Medicine22 July 2020 Collisions of other epidemics and Covid-19 To the recent highly appropriate Annals opinion pieces about the twin jeopardies of the Covid pandemic affecting those who also have to deal with a loss of health insurance (1) or opiate addiction (2), I would add a third problem; Covid and a surge in gun violence (GV). In the U.S. both concerns about suicides (3) and homicides are major issues. The latter are up 46-55 % in Chicago, Denver, New York City, Philadelphia and other major cities (4) increasing substantially since the first of March 2020. In addition gun sales are at an all-time high (5) which bodes ill for the future. As the saying goes, "It's the guns stupid, it's the guns". More guns simply mean more shootings. If only we could develop a vaccine to prevent GV! A national database registering all semi-automatic handguns and assault rifles would be a very good start. Author, Article, and Disclosure InformationAuthors: Steffie Woolhandler, MD, MPH; David U. Himmelstein, MDAffiliations: City University of New York at Hunter College, New York, New York, and Harvard Medical School and Cambridge Health Alliance, Cambridge, Massachusetts (S.W., D.U.H.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-1491.Corresponding Author: David U. Himmelstein, MD, City University of New York at Hunter College, 255 West 90th Street, New York, NY 10024; e-mail, dhimmels@hunter.cuny.edu.Correction: This article was corrected on 14 April 2020 to correct the citation in reference 3.Current Author Addresses: Drs. Woolhandler and Himmelstein: City University of New York at Hunter College, 255 West 90th Street, New York, NY 10024.Author Contributions: Conception and design: S. Woolhandler, D.U. Himmelstein.Analysis and interpretation of the data: S. Woolhandler, D.U. Himmelstein.Drafting of the article: S. Woolhandler, D.U. Himmelstein.Final approval of the article: S. Woolhandler, D.U. Himmelstein.Statistical expertise: S. Woolhandler.Administrative, technical, or logistic support: S. Woolhandler.Collection and assembly of data: S. Woolhandler, D.U. Himmelstein.This article was published at Annals.org on 7 April 2020. 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