The Commonwealth Fund recently explored the quality of health coverage for U.S. working-age adults in the first half of 2020. Among the findings: Two in five adults do not have stable health coverage.

The Commonwealth Fund recently conducted its latest Biennial Health Insurance Survey for a close look at American’s health insurance coverage among working-age Americans between January and June 2020. Researchers interviewed 4,272 adults ages 19 to 64 about their health insurance coverage. The survey, which is the latest study from Commonwealth Fund’s Biennial Health Insurance Survey series since 2001, explored the quality, extent, and affordability of coverage using three measures: whether people have insurance; whether those with insurance experienced a gap in coverage in the prior year; and whether high out-of-pocket costs and deductibles cause them to be underinsured, despite having continuous coverage throughout the year.

Researchers classified people as underinsured if their out-of-pocket costs (excluding premiums) over the prior year were equal to 10 percent or more of household income; if their out-of-pocket costs (excluding premiums) over the prior year were equal to 5 percent or more of household income for individuals living under 200 percent of the federal poverty level; or their deductible constitutes 5 percent or more of household income.

Although there was no significant change in coverage inadequacy from the months leading up to the onset of coronavirus in the U.S. and the months that followed, the ongoing economic impacts of COVID-19 may influence American’s ability to afford coverage in the future. In fact, researchers said the survey confirmed a continuing vulnerability exists in the ability of working-age adults to afford coverage and health care, which is likely to worsen amid the “economic downturn” of COVID-19.

“This survey examined Americans’ health insurance as our country slid into the worst public health and economic crisis in generations. What we found is troubling,” said David Blumenthal, M.D., president, The Commonwealth Fund, in a recent announcement about the survey. “Even before the pandemic, people were struggling with inadequate health coverage and mounting medical debt. It has never been more important to ensure that all U.S. residents have affordable, comprehensive coverage to survive this pandemic and beyond.”

Other key survey findings from the report:

  • More than two of five working-age adults are inadequately insured (43.4 percent)
  • The highest uninsured rates reported were among people of color, small business workers, people with low incomes, and young adults
  • One-quarter of adults in employer plans are underinsured
  • Half of adults who spent any time uninsured and those who were underinsured reported problems paying medical bills or said they have medical debt
  • Black Americans (45 percent) were significantly more likely than whites (35 percent) to report problems with medical bills
  • Many of those who reported problems paying medical bills also reported serious financial problems as a result from their medical debt, including damage to their credit ratings and depleted savings
  • Uninsured or underinsured adults often avoid or delay necessary health care and medications

Policy implications

The U.S. entered the COVID-19 pandemic with 30 million uninsured people and more than 40 million underinsured, and both numbers are expected to rise this year, according to study researchers, noting the Congressional Budget Office’s projections that the U.S. economy will contract by more than 5 percent in 2020 and 25 million fewer people will be working in the third quarter of 2020 in comparison to the end of 2019. “Coverage insecurity will leave people with mounting medical debt, as well as significant financial barriers to getting the health care they need to survive the pandemic and lead healthy and productive lives,” said study researchers.

Researchers underscored the need for federal and state level policies to move the nation toward universal and comprehensive coverage to provide relief to U.S. families. Although a single payer or “Medicare for All” approach is one path, they said the following steps may be more practical:

  • Expand Medicaid in the 12 states that have yet to do so or provide a federal fallback option for people eligible in those states
  • Enhance and extend the Affordable Care Act (ACA) marketplace subsidies both for premiums and cost-sharing
  • Allow more people with unaffordable employer plans to purchase subsidized coverage through the marketplaces, perhaps through a public plan
  • Increase outreach and enrollment efforts to inform people of their coverage options, particularly those who lose employer coverage
  • Ban non-ACA-compliant plans such as short-term policies that leave people exposed to catastrophic health care costs
  • Develop an autoenrollment mechanism that will enable people to enroll and stay enrolled in comprehensive coverage