Health Insurance Coverage Stable in 2020, Despite Pandemic

Rates of health insurance coverage remained mostly stable during the pandemic, with an estimated 1.6 more Americans gaining coverage in 2020, according to an early release from the CDC’s National Health Interview Survey (NHIS).

From 2019 to 2020, the uninsured rate dropped from an estimated 10.3% (33.2 million) to 9.7% (31.6 million), a non-significant difference, reported Robin Cohen, PhD, of the National Center for Health Statistics, and colleagues.

Adults ages 18-64 were most likely to lack health coverage, at 13.9%, and the uninsured rate was twice as high in states that did not expand Medicaid compared to those that did (20.8% vs 10.2%, respectively).

“That’s pretty striking,” Cohen said, explaining that while some of that difference in these states could be accounted for by public coverage, the difference was also attributable to a greater percentage of people in expansion states having private insurance.

Public insurance coverage in expansion and non-expansion states accounted for 22.5% and 16.7% of coverage for adults ages 18-64, respectively, while private insurance coverage rates were 69.2% and 64.3%.

Joan Alker, executive director and co-founder of the Center for Children and Families and a research professor at Georgetown University McCourt School of Public Policy in Washington, D.C, said that while there is likely some “wiggle room” around the specific estimates, there’s “no question we’re seeing a growing gap in uninsured rates in states that have expanded and states that have not, and I fear that chasm will continue to grow.”

Data for the 2020 NHIS involved 31,568 adults and 5,790 children, and the interviewing process was modified due to the pandemic, noted Cohen, with in-person surveys switched to phone only beginning on March 19, 2020. This led to “an over-representation of more affluent households,” the researchers noted.

Overall, 38% of respondents had public coverage, and 61.8% had private coverage (some individuals were covered by both public and private plans). Among children sampled for the survey, 5.1% were uninsured, 42.2% had public coverage, and 54.9% had private insurance. Adults 65 and older were most likely to be enrolled in a public health plan, at 95.9%.

Alker cautioned that while the overall results are likely true, the low rates of response (50%) and changes in data collection give her pause: “I would not approach these numbers assuming there’s a great deal of precision here,” she told MedPage Today.

Race, Ethnicity, and Income

With regard to race and ethnicity, Hispanic adults ages 18-64 were the group most likely to be uninsured across all racial groups, at 29.3%, followed by non-Hispanic Black adults at 14.6%, non-Hispanic white adults at 9.2%, and non-Hispanic Asian adults at 8.8%, the report showed.

Black adults ages 18-64 were the racial group most likely to have public health insurance, at 33.1%, followed by Hispanic adults at 23.0%. White adults accounted for the largest share of private coverage enrollment at 76.0%, with Asian adults close behind at 75.4%.

Cohen’s group also broke down the coverage data by income level and found that 25.3% of adults below 100% of the federal poverty level (FPL) lacked insurance and 25.0% of adults between 100% and less than 200% FPL were uninsured. Among adults earning less than 100% FPL, 56.3% reported having public coverage compared with 38.8% of those between 100% and less than 200% of FPL.

Of the adults whose income was 200% FPL or greater, 82.5% had private insurance, the report noted.

With regard to enrollment in the federal and state-based exchanges established as part of the Affordable Care Act (ACA), 3.8% of adults below age 65 were enrolled in exchange-based plans, and coverage was higher in families earning between 100% to less than 200% FPL compared with families who earned less than 100% FPL — 4.8% and 1.9%, respectively.

Exchange-based coverage was also higher among Hispanic individuals compared with white and Black individuals, at 4.2%, 3.7%, and 2.6%, respectively.

Data Collection in a Pandemic

The changes to the process of data collection cited in the report may seem trivial, but to some experts they’re not.

Alker said it’s unlikely the public will ever really know how many people were uninsured in 2020 because of the challenges of conducting surveys during the pandemic. Due to unreliable data and low response rates, she said, the Census Bureau won’t be releasing its American Community Survey 1-year estimates this fall.

She added that the NHIS had a “pretty small” completion rate, but researchers made a judgment call and decided the data were “good enough” to be shared.

And the survey “is showing us something, which is that there probably wasn’t a precipitous growth in the number of uninsured,” Alker added.

The following are some reasons the uninsured rates may not have spiked, Alker explained.

• First, many of the jobs lost during the pandemic were jobs that didn’t provide health insurance anyway. An analysis of what jobs uninsured people have in states that have not expanded Medicaid, conducted by Alker and colleagues, found that in nearly every state they researched, hospitality was “the number one industry” for employing uninsured workers. Hospitality was also “one of the hardest impacted industries” during the pandemic, she said.

• Second, she noted, a Medicaid “disenrollment freeze” enacted in March 2020 as part of the Families First Coronavirus Response Act prohibited states from dropping participants for reasons related to small fluctuations in income or paperwork problems during the pandemic.

• Lastly, the public now has a stronger safety net because of the passage of the ACA in 2010, Alker said. “People have more public coverage options for this recession than they did for the last big recession.”

She said that despite rationalizing the topline data, “I’m certainly taking these number with a little bit of a grain of salt.”