Americans who have suffered the most during the COVID-19 pandemic are also the most likely to be saddled with medical bill problems and debt, according to results from a new Commonwealth Fund survey. Adults ages 19 to 64 who contracted the virus, lost income, or lost their job-based health insurance coverage also reported higher rates of problems with medical bills and debt than people not affected by the pandemic in these ways. People who lost income experienced medical bill problems at the highest rates, especially those who also tested positive or became sick with COVID-19 or lost coverage.

The nationally representative survey of adults 19 to 64 fielded between March 9 and June 8, 2021, offers a glimpse of health care coverage and affordability in the United States during one of the most challenging economic periods in recent history. It examined pandemic-related coverage losses, current uninsured rates, and Americans’ ongoing struggles to pay their medical bills.

Key findings include:

• Black and Latinx/Hispanic adults were more likely to have medical bill problems and a loss of income during the pandemic.
  • More than half (55%) of Black and nearly half (44%) of Latinx/Hispanic adults said they had medical bill problems and debt, compared to one- third (32%) of white adults.
  • Overall, one-third of U.S. adults said their income fell during the pandemic, but Black, Latinx/Hispanic, and low-income adults were particularly hard hit. Forty-four percent of Black adults, and 45 percent of Latinx/Hispanic adults reported a loss of income.
• Insured and uninsured adults alike struggle to pay their medical bills, but those without coverage face greater challenges.
  • More than one-third of insured adults and half of uninsured adults said they had a medical bill problem or were paying off medical debt.
  • One-third (34%) of working-age adults with employer coverage reported medical bill or debt problems, as did nearly half (46%) of adults with individual and marketplace coverage.

• Relatively few adults lost job-based health insurance coverage during the pandemic. However, many of those who did were left exposed to health care costs.
  • Just 6 percent of working-age adults lost job-based coverage — whether through their own job or that of a spouse, partner, or parent — since the pandemic began. Of these individuals, 67 percent gained coverage elsewhere.
  • Just over half (54%) of people who lost coverage through their job and did not get COBRA were without coverage for three months or less. About 30 percent did not gain insurance until four to 11 months later, and 16 percent were uninsured for longer than a year.
• An estimated 10 percent of working-age adults were uninsured during the first half of 2021 — a smaller share than 2020 estimates from federal and private surveys.
  • The survey findings suggest that more people have gained insurance than lost it since the pandemic began. Federal efforts to help people maintain their Medicaid coverage, combined with state and federal efforts to encourage people to enroll in the Affordable Care Act (ACA) marketplaces and in Medicaid, have increased enrollment in both.
• Medical debt leaves people with lingering financial problems. Among adults who reported any medical bill or debt problem:
• • Thirty-five percent said they had used up most or all their savings to pay their bills.
  • Forty-three percent had received a lower credit rating as a result of their medical debt.
  • More than one-quarter (27%) were unable to pay for basic necessities such as food, heat, or their rent.

IMPLICATIONS

The authors note several policy options that could alleviate medical bill and debt problems and provide relief to many struggling U.S. families during the economic recovery. These include:

• Making the temporary American Rescue Plan marketplace subsidies permanent, which could reduce the number of uninsured by 4.2 million in 2022.
• Providing Medicaid-eligible adults in the 13 states that have not yet expanded their program a federal insurance option to cover an estimated 2.3 million uninsured people.
• Reining in deductibles and out-of-pocket costs in marketplace plans with new subsidies and rules.
• Allowing more people with unaffordable or skimpy employer plans to enroll in marketplace plans.

HOW WE CONDUCTED THIS STUDY

The Commonwealth Fund Health Care Coverage and COVID-19 Survey was conducted by SSRS from March 9 through June 8, 2021. The survey was conducted primarily via web with telephone offered as a call-in option among a nationally representative sample of 5,450 adults ages 19 to 64. Nearly all of the interviews were completed via an online survey (n=5,384) and a small percent of the interviews were conducted via phone call-ins (n=66).

Interviews were obtained through two sources: (1) a stratified address-based sample (ABS) of the population and (2) the SSRS Opinion Panel. Over half (n=3,464) of the completed interviews were obtained through ABS; 1,986 were obtained through the SSRS Opinion Panel.

The ABS sample was generated from the United States Postal Service (USPS) Computerized Delivery Sequence File (CDSF). The CDSF is a computerized file that contains information on all delivery addresses serviced by the USPS. The frame was divided into 32 strata defined by Census region, incidence of low- income households, incidence of Black residents, and incidence of Hispanic residents. Independent random samples were drawn from each stratum. By oversampling strata that have higher incidences of the target groups relative to other strata, their representation was increased in the sample while maintaining a probability sample design.

Panelists in the SSRS Opinion Panel are recruited randomly based on nationally representative ABS design. The SSRS Opinion Panel recruits hard-to-reach demographic groups via the SSRS Omnibus survey platform. The SSRS Opinion Panel was used to target groups with disproportionate non-response from the ABS completes and harder to reach populations. It was also used to obtain gender balance in the final sample of completed interviews.

Both samples were weighted to compensate for sample designs and patterns of non-response that might bias results. The weighting ensures that the demographic profile of the sample matches the profile of the target population.

The margin of error for the entire sample is +/- 1.8 percentage points.

Additional Pertinent Research

• U.S. Health Insurance Coverage in 2020: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020
• Do Americans Face Greater Mental Health and Economic Consequences from COVID-19? Comparing the U.S. with Other High-Income Countries
• Extend Marketplace Coverage to Insure More People in States That Have Not Expanded Medicaid
• How Auto-Enrollment Can Achieve Near-Universal Coverage: Policy and Implementation Issues