How laid-off Americans may ‘fall through the cracks’ of the health care system during COVID-19

For much of her adult life, Marsha Miller had been lucky enough to receive health insurance through an employer. But in March, when the novel coronavirus pandemic hit, that luck ran out, revealing how tenuous work-based health care coverage can be — not just for Miller, but for millions in the United States.

Miller said she had a great insurance plan when she worked recently as an executive assistant for a consulting company. Then, at the beginning of the year, she took a new job with a staffing firm, switching to a different plan that cost her about $200 a month. Just two months later, as most states began to take some kind of measures against the spread of COVID-19 and businesses began to feel the impact, she was laid off on March 16.

The recession triggered by the coronavirus pandemic is one of the worst in modern American history, with more than 11 percent of workers unemployed as of the beginning of July, down from a peak of nearly 15 percent in April. In a country where many rely on their employer for health care coverage, the economic crisis has also left a significant number of Americans uninsured. According to a report released by the nonpartisan organization Families USA during the week of July 13, an estimated 5.4 million workers in the U.S. are uninsured because of job losses they experienced from February to May this year. Another recent study by the Commonwealth Fund found that among people who lost a job or were furloughed because of the pandemic, two out of five had health care through their job, and one out of five of those respondents said that they or a spouse or partner was now uninsured.

Miller, who is 63, was told by her health care group that if she wanted to keep her plan, she’d need to pay the full insurance premium directly to her provider on her own. She initially assumed she’d be able to do so by collecting unemployment benefits, but a series of clerical errors resulted in months of delay in getting her unemployment application approved. Four months after losing her job, Miller said she had only received two weeks of unemployment benefits from the state of Florida, and thus been unable to pay the premium. (A spokesperson from Florida’s Department of Economic Opportunity said that the department has paid more than 1.7 million people state unemployment since March 15, and that “paying eligible Floridians the benefits they are owed continues to be DEO’s number one priority.”)

Some of the newly uninsured, like Miller, say they’ve found themselves in limbo — unable to qualify for Medicaid, but also unable to afford an Affordable Care Act plan or COBRA coverage from their recent employer — and for the moment, living without a safety net in the middle of a pandemic.

For Miller, who is due for a colonoscopy and has previously undergone surgery to remove polyps from her colon, the fear of contracting the virus while being unable to afford health care is compounded by the stress of delaying a procedure she knows she needs.

“I’m potentially sitting here with polyps right now, and no way to get a colonoscopy because I can’t afford it,” Miller told the PBS NewsHour.

Official numbers on the uninsured rate due to the COVID-19 crisis will not be available until next year, but recent reports offer a picture of a new challenge many Americans — and the health care centers serving the most vulnerable — may be facing in the coming year.

How the U.S. health care system has been affected by the pandemic

By early May, a month and a half after many businesses had begun to lay off or furlough workers, close watchers of the health care industry in the U.S. were already expecting the COVID-19 pandemic to have a significant impact on the uninsured rate.

“Because we have a system that provides health insurance through an individual’s employer, when we go through economic crises like the one we’re currently experiencing, it’s fully expected that some people losing their job today because of coronavirus are also losing their job-based health insurance,” Jennifer Tolbert, the state policy reform director at Kaiser Family Foundation, told NewsHour at the time.

WATCH: For many Americans, health coverage is tied to a job — and now they have neither

Historically, the number of uninsured people has risen dramatically during past economic crises. Following the 2008 Great Recession, the number of uninsured Americans reached an all-time high of 50.7 million. As of last December, this number was much lower, with just below 27 million non-elderly adults living without health insurance. Unlike the last recession, individuals today have more options for care if they lose their health insurance due to the Affordable Care Act, Tolbert said.

Americans who lose their health insurance now have the option to apply for coverage through the ACA marketplace, and if their income is low enough, they may qualify for Medicaid. But in states that chose not to expand Medicaid under the ACA, as many as 2 million Americans are not able to access this option, according to the Kaiser Family Foundation. COBRA, the stopgap coverage provided by some employers to people who have lost their jobs, was described by many of the newly unemployed who spoke to the PBS NewsHour as prohibitively expensive.

“COBRA was ridiculously expensive, who can afford that? It was somewhere in the vicinity of $700, $800 a month,” said Lisa Westerman, 61, who was laid off at the end of February from her job as a manager and technician at a family entertainment park in Houston that offered attractions such as go-karts and batting cages.

“At the end of the day, we know it’s really hard to connect people with coverage. And so there are going to be people who fall through the cracks,” said Molly Smith, vice president of coverage and state issues at the American Hospital Association.

Living uninsured and in limbo

For some Americans who were already dealing with health problems, losing health insurance during the pandemic has created extra anxiety during an especially stressful moment in history.

Tamara Ames, a 58-year-old IT consultant based in Denver, came down with COVID-like symptoms about a month before she was laid off from her job. She said she had a fever for weeks, and was too nervous to risk going into a health center during the outbreak to get tested, so she never confirmed whether she indeed had COVID-19. Ames said she lost her insurance on April 30, and has been living without reliable coverage since.

“I’d wake up at 2 or 3 in the morning and not be able to go back to sleep because of the uncertainty of the situation,” Ames said, adding that she found herself wondering, “What if those unemployment benefits run out? There’s only so much in that bank. What happens if I get sicker after that point?…There were so many days that I lived in this fugue state,” Ames said.

Ames managed to get a new job as a consultant with Schwab, but has since moved back in with her parents to save money. She’s staying isolated until she starts her job and is able to receive health care through her new employer, and has been ordering groceries to be delivered to avoid going outside for fear of catching the virus. But even her situation — finding a new job after losing one and being able to order groceries for delivery — is more fortunate than many.

Terilee Henderson, who was laid off from a mortgage managing company before the pandemic, had been offered a job through the 2020 census and expected to receive health insurance through that new position. But the work was delayed due to COVID-19 concerns, and now Henderson, who is immunocompromised, is living without insurance.

“Right now I am in limbo of going back to work, and then I’ll have my coverage again, or if that doesn’t happen, coughing [up] out of pocket for non-employer sponsored health insurance,” said Henderson, who lives in Douglas County, Colorado, and is due to have an injection for her osteoporosis this month. She may qualify for Medicare when she turns 65, but that’s five months away.

Joel Kilgore of Raleigh, North Carolina, doesn’t have any immediate health concerns, but the recently laid-off 49-year-old has had three spinal neurosurgeries in the past. He worries that if he’s hit with an additional medical cost while uninsured, he wouldn’t be able to pay it. He’s been receiving unemployment benefits from the state, but the extra $600 per week allocated by Congress he received is set to expire at the end of the month, which Kilgore said has further compounded his stress.

“Almost all my daily thoughts and daily activities center around, what am I going to do if I somehow become unhealthy?” he said.

Kilgore looked into options on the federally run health care exchange, but said he couldn’t afford the cost of plans he qualified for right now.

After incurring serious debt from previous medical surgeries, he said he was so worried about the potential damage coronavirus could wreak on his finances that he warned his family not to push for treatment as long as he didn’t have health insurance.

“If I do contract COVID and find myself in very dire straits, I’ve instructed my family to not take any heroic measures to keep me alive. I’m not going to saddle my family with a million dollar plus bill for something that this country should have been better on top of and working harder to get under control,” Kilgore told the NewsHour. He said that shouldering a large bill that rendered him unable to take out a loan or buy a house in the future sounded “worse than death” itself.

Health clinics feel effects of the recession

As recently laid-off Americans navigate their new health care realities, clinics that primarily serve low-income patients are bracing to see an uptick in newly uninsured clients seeking care due to the pandemic. The National Association of Community Health Centers (NACHC), a network of clinics across the U.S. that receive federal funding to care for patients that cannot afford premium health care, had projected a $7.6 billion loss due to the pandemic as of April. The CARES Act did appropriate $1.3 billion to more than 1,300 of these health centers as part of the federal coronavirus response.

Dr. Ron Yee, chief medical officer for NACHC, said that one in 12 U.S. residents already received care from the centers in his network before the pandemic, and 23 percent of those patients were uninsured. He said that some states’ decision not to expand Medicaid could make it harder for some health care centers to take on a crush of new patients. Without extra Medicaid dollars to refund providers, clinics are limited in their ability to accommodate people who cannot afford to pay.

READ MORE: How uninsured patients can get help during COVID-19 pandemic

As of July 1, 13 states had elected not to expand Medicaid under the Affordable Care Act. Two of these states — Texas and Florida — have recently seen dramatic spikes in the number of COVID-19 cases.

“For those 30-plus states that did Medicaid expansion, those health centers are much more able to take on the newly uninsured,” Yee said. “If you’re in a non-expansion state, that doesn’t leave too many options” for people who have recently lost their health insurance.

For AccessHealth, which operates five clinics in Fort Bend County, Texas, about 55 percent of their patients are typically uninsured, CEO Mike Dotson said. While they had yet to see a significant uptick in newly uninsured patients seeking care, Dotson expects numbers to go up as the recession lingers into the fall.

Dotson said around 90 percent of AccessHealth patients are minorities, representing populations that have been disproportionately affected by the virus. The COVID-19 Tracking Project reports that Black Americans account for at least 23 percent of virus deaths where race is known, but only make up about 13 percent of the U.S. population. Native Americans and Hispanic or Latino populations are also dying of COVID-19 at higher rates than Asian or white Americans.

The Brookings Institution reported that these disparities could be caused by a number of factors, including the fact that these communities may be more vulnerable in health and economic positions.

These COVID-19 disparities are reflective of historic gaps in wealth and income that Black communities in America have always faced, NewsHour economics correspondent Paul Solman recently reported. Michigan State University economics professor Lisa Cook told Solman in a story that aired mid-July that because many Black Americans work in low-wage service jobs, they embody the adage “last hired, first fired” during recessions.

“The ‘last hired’ means that there is not the ability to accumulate income,” said Cook. “That makes African Americans less able to weather such a storm.” Economist Trevor Logan said this level of economic insecurity makes many Black Americans more likely to “need to be employed in the places where they are essential workers,” and thus more vulnerable to COVID-19.

Although the Affordable Care Act increased health coverage rates for Americans across the board, 11.5 percent of Black Americans were uninsured as of 2018. This number was higher among Hispanic and Native American populations — 19 and 21.8 percent of whom were uninsured, respectfully.

Sindy Benevidez, the president of the League of Latin American citizens, noted in a statement to the NewsHour that members of the Latino community are less likely than members of other demographic groups to have coverage to begin with, due to lack of employer-sponsored plans or citizenship restrictions. Without federally qualified health centers like Dotson’s, Benevidez said, many Latinos would “not be able to walk into a doctor’s office…and expect care.”

Dotson said AccessHealth is “predominantly the safety net” for folks who cannot afford health insurance in Fort Bend County, a region in greater Houston which has processed more than 11,000 unemployment claims since the beginning of May. “My assumption is, as folks become unemployed and insurance benefits go away, we are generally the provider that would cater to” them, he said.

The CEO said that for the time being, AccessHealth’s clinics have seen a drop in patients during the pandemic despite their efforts to provide telehealth services. This is particularly true among Medicaid patients who access their OB-GYN and pediatric services, which typically fuels a lot of revenue for AccessHealth.

Dotson said that Access Health is preparing for their uninsured patient population to increase “if there’s not a vehicle to connect these folks to benefits,” such as Medicaid. He added that AccessHealth would try to connect with funders like the Episcopal Health Foundation to provide additional financial support for both existing and new uninsured patients in the coming months.

The likely rise in uninsured patients, coupled with a drop-off in business due to the pandemic, is worrying to some health clinic owners who typically rely on revenue from insured patients to supplement care for those who can’t afford it.

Brittany Martinez-Clark, who operates a family clinic in New Albany, Mississippi, said that although most of her patients are on Medicaid or are uninsured, her business counts on patients with private health insurance plans to help balance the books. Martinez-Clark said that after a major commercial refrigerator factory in town shut down back in May, patients who had previously received insurance through that employer would now have to pursue other plans.

“The effects of those closures and that commercially insured income that we depend on, we will feel that for years,” Martinez-Clark said. She noted that the difference in money that the clinic receives for patients with employer-sponsored insurance versus those without it is about $100.

As the pandemic shows no sign of letting up, the concern among many health providers is that people may delay regular wellness checkups or vaccinations due to fear of contracting COVID-19 at the doctor’s office, or racking up a costly bill.

“We don’t know exactly how people will respond in the current environment, but what we do know from ongoing data from uninsured individuals is that they are more likely to delay seeking care because of cost,” said Jennifer Tolbert of the Kaiser Family Foundation.

“What scares me is that, if we’ve got pockets of our population that are foregoing medical care right out of fear” of the virus, said AccessHealth’s Mike Dotson, they might not receive treatments for other conditions, such as diabetes, or fall behind on immunizations for their kids.

This rapid drop in insured Americans threatens a blow to the long-term health of the U.S., experts say. And the landscape for coverage could change again very rapidly for both patients and providers in the coming years, bringing more uncertainty. The Trump administration is still advocating to have the Obama-era health care law struck down in its entirety, which would end insurance for 20 million Americans.

In February, before the COVID-19 pandemic really hit the U.S., a vast majority of voters ranked health care costs as a top priority issue, no matter the political party. And many newly uninsured patients who spoke with the NewsHour more recently said that navigating the current system during the pandemic has made them more inclined than ever to keep the issue of health care top-of-mind should they vote in the presidential election this November.

“The fact that Americans’ health care is tied to having a job, especially now with so many people that are out of work, it’s absolutely asinine ridiculous,” Terilee Henderson said.