An estimated 257,000 people in North Carolina lost their health insurance due to job loss during the first six months of the COVID-19 pandemic, according to estimates released Monday in the North Carolina Medical Journal, a publication of NC Institute of Medicine and The Duke Endowment.
That’s on top of the more than 1.1 million people who were already uninsured in North Carolina in 2019. Last year, 11.4% of the state’s population was uninsured — one of the highest rates in the country — and above the nationwide average of 9.2%.
The estimated increase during the pandemic would amount to a 3% increase in the uninsured rate statewide. The analysis, conducted by Mark Holmes at UNC Gillings School of Global Public Health, is based on both historical trends in the relationship between uninsurance and unemployment in North Carolina and a national June survey on loss of employment and insurance. According to that survey, by the Commonwealth Foundation, 21% of respondents who said that they or a partner had coverage through a job affected by COVID-19 reported that at least one of them is now uninsured.
Doctors serving uninsured people in the Triangle say they are seeing the strain firsthand.
“We have seen a change in people being laid off from jobs, not knowing if they’re going to go back to a job. Even with our patients that are working but maybe not working enough to qualify for health insurance, there’s uncertainty with even being able to get basic medications— insulin particularly,” said Elizabeth Campbell, medical director of Urban Ministries. The private facility provides low-cost services to uninsured and low-income Wake County residents.
In the first few months of the pandemic, people were more hesitant to seek care because they were concerned about COVID-19 exposure, Campbell told The News & Observer in a phone interview. But now the clinic is seeing a rush of new patients seeking treatment at her clinic, many of them newly uninsured.
The clinic is currently processing about eight to 10 new patient applications a week, said Campbell, compared to between four and six before the pandemic. The clinic usually has about 1,500 patients a year, but is expecting between 1,800 and 2,000 this year.
Pandemic-related job loss
Recent U.S. Census surveys indicate that people who’ve lost employment during the pandemic are experiencing loss of insurance at far higher rates. According to the most recent survey of nearly 1,400 people in North Carolina during early October, roughly 15% of people who reported that they or a household member experienced a loss of employment income reported being uninsured. Roughly four percent of those who reported that they hadn’t lost income said they were uninsured. (The Census notes that conclusions from the data are limited by the small sample size and high margin of error.)
Lack of insurance is hitting people of color disproportionately hard, according to the Census survey. Roughly 17% of Hispanic people reported being uninsured, along with 12% of Black respondents and 6.6% of white respondents.
Losing health insurance has put some of Campbell’s patients in dangerous situations, forcing them to go months without necessary treatment and medications.
“I have a couple patients that have said, you know, ‘I never thought I’d find myself in this situation. I had a good job, I had reliable employment,’” she said.
Increase in Medicaid enrollment
The loss of income and private health insurance has sent tens of thousands of people in North Carolina seeking public coverage.
In August, 2,337,492 North Carolinians were covered by Medicaid, up from 2,186,142 people in February, according to the North Carolina Department of Health and Human Services. That’s an increase of 151,350, or 7%. Medicaid enrollment increased by over 9% in Wake County, one of the highest increases in the state.
Between the same months last year, enrollment decreased by more than 5,000. The same trends are true across the country: enrollment from February to June increased in nearly every state, after declines from 2017 to 2019. According to the June survey by Commonwealth, seven percent — one-third of those who lost coverage — were newly insured by Medicaid or a similar state plan.
But for many uninsured people in North Carolina, Medicaid is not an option.
North Carolina is one of 12 states that has not adopted Medicaid expansion, a major piece of the Affordable Care Act, which expands eligibility for Medicaid to people with incomes below 138% of the federal poverty level. In North Carolina, eligibility is far more limited: for non-elderly adults to qualify for full Medicaid in North Carolina, they must either have a qualifying disability or dependent children in the house.
For parents, the income eligibility is less than half of the poverty point, meaning that hundreds of thousands of North Carolinians living in and near poverty cannot qualify for health coverage through Medicaid.
People who don’t meet these requirements but also don’t make enough money to buy private insurance on the marketplace are stuck in what’s known as the “coverage gap.”
An estimated 178,000 people in North Carolina who lost their jobs between March and May fell into the coverage gap, according to an analysis by the Kaiser Family Foundation.
If the state expanded Medicaid, over 450,000 people who were uninsured before the pandemic would become eligible for Medicaid, according to a report by KFF. About 282,000 people who have become uninsured during the pandemic would become eligible.
Lack of public awareness of affordable options
Changes to Marketplace enrollment rules during the pandemic mean that many more people may be eligible for affordable coverage. But healthcare advocates say that lack of public education has limited the number of people taking advantage of these programs.
Normally, people can only enroll in Marketplace plans during the Open Enrollment Period or for 60 days before or after losing health coverage, called the Special Enrollment Period.
But, due to FEMA declaring COVID-19 a national emergency, people who qualified for SEP but missed the deadline because of COVID-19 impacts may be eligible for another SEP.
According to healthcare advocates, this change was not adequately publicized.
Julieanne Taylor, supervisor of the Health Insurance Navigator Project at Charlotte Center for Legal Advocacy, said that her team only found out about the change in August when one of her colleagues was helping a client enroll in coverage. Instead of the usual 60-day range listed on the SEP application, the online form offered an option to enroll to people who had experienced a loss of coverage dating back to January 1, 2020.
“A lot of folks could have had quality health care, affordable healthcare to take care of things even outside of COVID, but they haven’t had that peace of mind because there hasn’t been any clear messaging,” said Mark Van Arnam, co-director of the North Carolina Navigator Consortium, a project of Legal Aid of North Carolina that assists people with accessing affordable health insurance.
The 2021 open enrollment period opened Sunday, and runs through December 15.
Taylor said that she’s seen a lot of interest in enrollment. Even before the start of the open enrollment period, all of the appointments with healthcare navigators at her office in Charlotte were booked up.
Given “all of the confusion and misinformation and people having lost their jobs,” she wasn’t expecting so much interest, she said.
“People are being more proactive than we thought they would be. It’s been a big surprise, and it’s great to see.”
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