As of April 20, more than 780,000 individuals had confirmed COVID-19 in the USA.1 In addition to threatening health, this outbreak could have financial consequences for those affected. One analysis estimated that 5.7 million Americans at high risk for severe COVID-19 are uninsured.2 Healthcare costs could deter such individuals from seeking care, particularly among disadvantaged groups, while burdening household finances. We analyzed a nationally representative survey to identify individuals at elevated risk for severe COVID-19 and, among these, those at high risk of financial toxicity from care at the start of the epidemic.
We analyzed the 2018 Behavioral Risk Factor Surveillance System (BRFSS), a survey of the noninstitutionalized population conducted by the Centers for Disease Control (CDC). We identified the “COVID-19-increased risk” population based on CDC guidance2, 3: individuals 65 and older, and non-elderly adults with COPD, asthma, heart disease, severe obesity (BMI ≥ 40), kidney disease, and diabetes.
We first identified demographic characteristics and relevant state-level policies associated with being in the COVID-19-increased risk group among adults < 65. We used multivariable logistic regressions adjusted for age and sex to examine the association between being at COVID-19-increased risk (vs not increased risk) and five characteristics/state-level policies: race, income, urban/rural county of residence, residence in a state that had implemented the Affordable Care Act’s Medicaid expansion as of January 2018,4 and residence in a state that had issued a “stay-at-home” order as of March 30, 20205 (as one indicator for outbreak risk).
We next examined the rate of “inadequate insurance” within the high-risk population of any age. Inadequate insurance was defined as being uninsured or underinsured, i.e., insured, but having skipped a doctor visit within the last year because of cost. We examined the relationship between the five characteristics/state-level policies listed above and inadequate insurance in separate age- and sex-adjusted regressions.
We used STATA/SE 16.1 for all analyses, with weights and appropriate methods to account for the BRFSS’ complex sampling procedures. Analysis of the BRFSS does not constitute human subjects research per the Cambridge Health Alliance IRB.
Table 1 displays data on the prevalence of risk factors for severe COVID-19 among those < 65 years. Blacks, American Indians/Alaska Natives, and those of “other” race were significantly more likely, and Asians less likely, to be in the COVID-increased risk population relative to whites. Persons with lower (vs. high) incomes were more likely to be increased risk, as were those living in rural counties, Medicaid non-expansion states, and states that had not issued a stay-at-home order.
Within the COVID-19-increased risk population of adults, 16.9% (or 18.2 million individuals) were un- or underinsured. Among this increased risk group, those with low incomes, residing in a rural area, and of non-white race had higher rates of inadequate insurance (Table 2). High-risk persons living in Medicaid non-expansion states had 52% higher odds of being inadequately insured relative to those in expansion states (95% CI 1.43, 1.61; p < 0.001), and high-risk individuals residing in states that had not issued stay-at-home orders had 23% higher odds of inadequate insurance relative to those in other states (95% CI 1.16–1.30).
At the start of the outbreak, 18 million adults at increased risk of severe COVID-19 were inadequately insured and hence at risk of delay in seeking care because of cost concerns and of financial toxicity if hospitalized. Traditionally disadvantaged groups—racial minorities, low-income persons, and rural residents—were more likely to be at risk of severe COVID-19 (consistent with the experience of previous viral respiratory epidemics6) and of financial harm. Those living in states that failed to expand Medicaid or issue a stay-at-home order were also at greater risk of severe disease and inadequate coverage.
Gaps in insurance coverage, and states’ decisions to reject Medicaid expansion and defer prevention measures, may hence exacerbate the damage wrought by the COVID-19 epidemic, as well as health disparities. Rising unemployment after the onset of the epidemic in the USA will likely translate into health coverage losses that could further widen these gaps; our estimates of uninsurance and underinsurance are likely underestimates. These findings provide support for steps taken to address inadequacies in coverage for the diagnosis and treatment of COVID-19 and for the consideration of additional policies that could expand coverage during the economic downturn.
Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering at Johns Hopkins University. https://coronavirus.jhu.edu/map.html. Accessed Apr 20, 2020.
Koma W, Claxton G, 2020. How Many Adults Are at Risk of Serious Illness If Infected with Coronavirus? The Henry J Kaiser Family Foundation. March 2020. https://www.kff.org/global-health-policy/issue-brief/how-many-adults-are-at-risk-of-serious-illness-if-infected-with-coronavirus/. Accessed Mar 24, 2020.
Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html. Published February 11, 2020. Accessed Mar 31, 2020.
Status of State Action on the Medicaid Expansion Decision. The Henry J. Kaiser Family Foundation. 2020. Available from: https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed Mar 31, 2020.
State Data and Policy Actions to Address Coronavirus. The Henry J Kaiser Family Foundation. March 2020. https://www.kff.org/health-costs/issue-brief/state-data-and-policy-actions-to-address-coronavirus/. Accessed Mar 30, 2020.
Dee DL, Bensyl DM, Gindler J, et al. Racial and ethnic disparities in hospitalizations and deaths associated with 2009 pandemic Influenza A (H1N1) virus infections in the United States. Ann Epidemiol. 2011;21(8):623-630. https://doi.org/10.1016/j.annepidem.2011.03.002
Dr. Hawks received funding support from Institutional National Research Service Award T32HP32715 and from the Cambridge Health Alliance.
Conflict of Interest
The authors report no financial conflicts of interest. Adam Gaffney, David Himmelstein, Steffie Woolhandler, and Danny McCormick serve as leaders of Physicians for a National Health Program (PNHP), a non-profit organization that favors coverage expansion through a single-payer program; however, none of them receives any compensation from that group, although some of Dr. Gaffney’s travel on behalf of the organization is reimbursed by it. Drs. Bor and Hawks are members of the organization.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Gaffney, A.W., Hawks, L., Bor, D.H. et al. 18.2 Million Individuals at Increased Risk of Severe COVID-19 Illness Are Un- or Underinsured. J GEN INTERN MED 35, 2487–2489 (2020). https://doi.org/10.1007/s11606-020-05899-8