FROM SAFETY NET TO SOLID GROUND Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. Almost Half of Adults in Families Losing Work during the Pandemic Avoided Health Care Because of Costs or COVID-19 Concerns Dulce Gonzalez, Stephen Zuckerman, Genevieve M. Kenney, and Michael Karpman July 2020 The COVID-19 pandemic and resulting economic downturn are posing new challenges for families seeking health care. Not only have many providers rescheduled patient visits or closed their practices because of the pandemic, but patients have also shied away from seeing their regular physicians (Hamel et al. 2020).1 In addition, significant material hardship among the large number of adults whose families have lost jobs or work-related income during the pandemic makes it difficult for families to afford the care they need (Karpman et al. 2020). Forgone or delayed care because of cost or fear of exposure to the novel coronavirus will not affect everyone the same way. Relatively healthy people can skip some basic health care services without adverse consequences. Moreover, not all health care is equally important: prepandemic evidence suggests a large share of US spending on health care is low value or unnecessary (Carroll 2017; Mehrotra and Prochazka 2015; Shrank, Rogstad, and Parekh 2019).2 However, when people with chronic conditions forgo care, deleterious and potentially avoidable health effects can emerge that may be harder to treat later. Similarly, people have fewer opportunities to receive important health screenings and other preventive care during the pandemic, leading to delayed detection of serious health problems, like cancer, and to increased risk of preventable health problems. Evidence already shows children are missing regularly scheduled immunizations, and pediatricians and other health providers are struggling to get them back on track (Santoli et al. 2020).3 Fears about exposure may be strongest among people experiencing acute health care problems, who worry about going to an emergency department and making contact with COVID-19 patients. Some anecdotal reports suggest this is leading to an increase in deaths at home from heart attack and stroke,4 and emerging evidence shows the number of people treated at hospitals has dropped relative to prepandemic figures (Garcia et al. 2020; Hartnett et al. 2020; Jiang et al. 2020). In this brief, we examine health care affordability problems and avoidance of care due to concerns about exposure to the novel coronavirus during the pandemic. To do so, we use new data from the first wave of the Urban Institute’s Coronavirus Tracking Survey, a nationally representative survey of nonelderly adults conducted May 14 through 27, 2020. Anecdotal and quantitative evidence show forgone or delayed care amid the pandemic, including recent polls capturing patients’ reluctance to visit health care providers because of concerns about exposure to the coronavirus.5 Our data add to that body of work by highlighting the groups of people disproportionately affected. We first consider whether adults in families who have lost work or work-related income are more likely to report that they or a family member have forgone care because of costs or fear of exposure to the virus than those who have not experienced employment disruptions. These adults and their families are already facing the financial consequences of the pandemic and may face further health consequences if they are more likely to skip needed care. We then examine forgone care reported by adults in families losing work or work-related income, including those in families with low incomes, where someone is uninsured, where someone has a chronic condition, or that include children under age 19. Results Almost half (45.5 percent) of adults in families losing work or work-related income reported unmet need for medical care in the family because of costs in the 30 days before the survey and/or avoidance of care because of concerns about exposure to the coronavirus. Overall, 15.9 percent of nonelderly adults reported unmet need for medical care in the family because of costs in the last 30 days; 30.0 percent reported that someone in the family avoided getting care at a doctor’s office, clinic, hospital, or other health care provider because of worries about coronavirus exposure; and 37.3 percent reported one or both of these issues (figure 1). Adults in families losing work or work-related income because of the outbreak fared worse: They were more likely than adults whose families did not lose work or income to report that their families had unmet need for medical care because of costs (22.3 percent versus 10.9 percent) and that someone in the family avoided getting care because of coronavirus concerns (36.1 percent versus 25.3 percent).6 They were also nearly 15 percentage points more likely to report one or both of these reasons for avoiding care than adults whose families have not lost work or income (45.5 percent versus 30.9 percent).7 2 FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, COVID-19 RISKS FIGURE 1 Unmet Need for Medical Care in the Family and Avoidance of Care Due to Coronavirus Concerns Reported by Adults Ages 18 to 64, Overall and by Whether Someone in the Family Lost Work or Work-Related Income Because of the Coronavirus Outbreak, May 2020 All adults Adults in families losing work or work-related income Adults in families not losing work or work-related income 15.9% Unmet need for medical care in the family because of 22.3% costs in the last 30 days 10.9%*** 30.0% Someone in the family avoided getting care over worries 36.1% about coronavirus exposure 25.3%*** 37.3% Unmet need for medical care in the family and/or 45.5% someone in the family avoided getting care 30.9%*** URBAN INSTITUTE Source: Urban Institute Coronavirus Tracking Survey, wave 1. Notes: Unmet need for medical care is reported for the past 30 days and includes prescription drugs; general doctor visits; specialist visits; medical tests, treatment, or follow-up care; dental care; mental health care or counseling; and treatment or counseling for alcohol or drug use. The measure on avoidance of care does not have a reference period. We define family as the respondent, their spouse or partner, and any of their children or stepchildren under 19 who live with them. The survey was conducted May 14 through 27, 2020, and 93.1 percent of respondents completed the survey by May 20. */**/*** Estimate differs significantly from adults in families losing work or work-related income at the 0.10/0.05/0.01 level, using two-tailed tests. Among adults in families losing work or work-related income because of the outbreak, more than half of those with lower incomes and those with uninsured family members, those in families with chronic conditions, and parents living with children under 19 were in families that avoided health care because of cost or concerns about exposure to the coronavirus. To assess the compounded impacts of lost employment and forgone health care during the pandemic, we now focus solely on adults in families losing work or work-related income. Among this group, about one in three adults (34.4 percent) in families where someone is uninsured reported unmet need for medical care in the family because of costs in the 30 days before the survey, compared with about one in five (19.4 percent) adults in families where everyone has health insurance. Close to one in three (31.4 percent) adults with lower incomes (family income below 250 percent of the federal poverty level) reported unmet need for medical care in the family, compared with 13.5 percent for those with higher incomes (at or above 250 percent of the federal poverty level). This FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, C OVID-19 RISKS 3 figure was 28.9 percent for adults in families where someone has a chronic condition, which was nearly twice as high as that for adults in families where no one has a chronic condition (15.9 percent). Parents living with children under 19 were also more likely than adults not living with children under 19 to report an unmet need for care (28.6 percent versus 18.5 percent). By race/ethnicity, roughly equal shares of Hispanic adults and non-Hispanic Black adults reported unmet need for care because of costs (28.5 percent and 28.1 percent); these adults were also about 10 percentage points more likely to report going without care for cost reasons than non-Hispanic white adults (18.2 percent). As shown in table 1, Hispanic adults in families with noncitizens and in families where all members are citizens reported similar unmet needs for care because of costs (28.2 percent versus 28.8 percent). TABLE 1 Share of Adults Ages 18 to 64 Whose Families Lost Work or Work-Related Income Because of the Coronavirus Outbreak Reporting Unmet Need for Medical Care and Avoidance of Care in the Family, by Reason for Not Getting Care, May 2020 Reason for Not Getting Care Coronavirus Cost and/or Costs exposure concerns exposure concerns Family health insurance status Someone in the family is uninsured^ 34.4% 33.2% 50.6% All family members are insured 19.4%*** 36.8% 44.3%* Family income Below 250% of FPL^ 31.4% 42.5% 55.3% At or above 250% of FPL 13.5%*** 29.9%*** 36.0%*** Chronic conditions in the family Someone has a chronic condition^ 28.9% 41.0% 52.9% No one has a chronic condition 15.9%*** 31.3%*** 38.3%*** Presence of children in the family Any children^ 28.6% 45.2% 57.3% No children 18.5%*** 30.6%*** 38.4%*** Race/ethnicity and family citizenship status Non-Hispanic white^ 18.2% 32.8% 40.8% Non-Hispanic Black 28.1%*** 39.3%* 48.9%** Hispanic 28.5%*** 41.4%*** 53.3%*** Any noncitizen in the family 28.2%*** 42.0%** 53.4%*** All family members are citizens 28.8%** 40.8%** 53.2%*** Source: Urban Institute Coronavirus Tracking Survey, wave 1. Notes: FPL = federal poverty level. Unmet need for medical care because of costs is reported for the past 30 days and includes prescription drugs; general doctor visits; specialist visits; medical tests, treatment, or follow-up care; dental care; mental health care or counseling; and treatment or counseling for alcohol or drug use. The measure on avoidance of care does not have a reference period. Citizens are both US-born and naturalized citizens. Estimates for other race (non-Hispanic adults who are not Black or white or are more than one race) are suppressed because of sample size restrictions. We define family as the respondent, their spouse or partner, and any of their children or stepchildren under 19 who live with them. The survey was conducted May 14 through 27, 2020, and 93.1 percent of respondents completed the survey by May 20. */**/*** Estimate differs significantly from reference group (^) at the 0.10/0.05/0.01 level, using two-tailed tests. 4 FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, COVID-19 RISKS Among adults in families losing work or work-related income, certain adults were more likely to report that someone in the family avoided getting care because of worries about coronavirus exposure: those in families with low incomes (42.5 percent), those in families where someone has a chronic condition (41.0 percent), and parents (45.2 percent). In contrast, 29.9 percent of adults with higher incomes, 31.3 percent of adults in families where no one has a chronic condition, and 30.6 percent of people not living with children under 19 reported avoidance of care because of worries about exposure to the coronavirus. Additionally, Hispanic adults and non-Hispanic Black adults were more likely to report avoiding care than non-Hispanic white adults (41.4 percent and 39.3 percent versus 32.8 percent). We find no significant differences by family health insurance status in the share of adults reporting avoided medical care because of exposure concerns. Finally, 57.3 percent of parents living with children under 19 in families that lost work or income reported an unmet need for medical care because of costs and/or avoiding getting care because of coronavirus concerns, as did 55.3 percent of adults with lower incomes, 53.3 percent of Hispanic adults, 48.9 percent of non-Hispanic Black adults, and 52.9 percent of adults in families where someone has a chronic condition. Adults in families where someone is uninsured were about 6 percentage points more likely than those in families where everyone has health insurance to report either or both of these issues (50.6 percent versus 44.3 percent). Among adults not losing work or work-related income, similar patterns hold for those in families where someone has a chronic condition, parents of children under 19, adults with lower incomes and uninsured family members, and Hispanic adults (data not shown). Discussion The unprecedented decline in economic activity because of the current public health crisis threatens to worsen existing health care disparities and upend family financial stability for many, especially those who lose employment. Our findings show that nonelderly adults in families losing work or work- related income because of the COVID-19 pandemic are more likely to face health care affordability challenges than adults in families not experiencing these negative economic effects. Among adults losing work or work-related income, more than one in five report that their family had an unmet need for medical care because of costs in the month before the survey. Within this group, adults in families where someone is uninsured reported much higher unmet need for care because of costs than those in families where everyone is insured, illustrating the protective role health insurance plays in promoting access to needed health care. Though health care affordability was a pressing concern before the pandemic, the currently elevated need for health care brings these challenges to the fore. Affordability concerns and disruptions in care may worsen as the health insurance coverage many families get through their employers terminates because of job loss (Karpman, Zuckerman, and Peterson 2020). In addition to affordability challenges, many nonelderly adults and their families are also forgoing potentially critical health care over fears of being infected with the novel coronavirus. Nearly one in three adults reported that someone in their family did not get health care because of concerns about FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, C OVID-19 RISKS 5 exposure. Among adults in families losing work or work-related income, these concerns were more prevalent among people in families with chronic conditions, parents living with children under 19, adults with low incomes, and adults who are Black or Hispanic. Avoiding or delaying needed health care, especially for people with ongoing medical needs or who have experienced the outbreak’s negative economic consequences, could adversely affect individual long-term health and widen racial/ethnic and socioeconomic health disparities that existed before the pandemic (Weinstein et al. 2017). Though medical visits among older patients appear to be rebounding to prepandemic volumes, visits for specialties, such as behavioral health and pediatrics, remain well below the baseline (Mehrotra et al. 2020). For children, missing needed medical visits to ensure healthy growth and development risks negative long-run effects on their health and well-being. Emerging evidence shows reductions in vaccinations ordered for and administered to children and declines in well-child visits, placing children and others in the community at risk for otherwise preventable diseases (Santoli et al. 2020).8 These findings show that addressing both affordability and exposure concerns is necessary for ensuring that people receive the health care they need during the pandemic. The next relief package negotiated by Congress offers a critical opportunity to help families afford care. One key element of improving affordability will be protecting people losing both their jobs and their health insurance coverage from becoming uninsured. But even among those who can maintain coverage, reduced incomes will make it harder to pay for out-of-pocket health care costs associated with deductibles, copayments, and other cost-sharing requirements under their health plans. The Health and Economic Recovery Omnibus Emergency Solutions, or Heroes, Act passed by the House would protect coverage and improve affordability for many people losing employer-sponsored insurance by fully subsidizing premiums for COBRA coverage until January 31, 2021. Other strategies, such as rapid Medicaid eligibility expansions, more generous premium tax credits and cost-sharing reductions for Marketplace plans, and expanded eligibility for those Marketplace subsidies, would be needed to reach people who are neither covered by an employer plan nor eligible for COBRA (Blumberg and Mann 2020; Blumberg et al. 2020). Continuation of the emergency assistance authorized by the Coronavirus Aid, Recovery, and Economic Security, or CARES, Act—which included a $600 weekly supplement for unemployment insurance benefits and direct cash payments to US households—would also mitigate the negative impact of the recession on families’ abilities to pay for health care. In addition to ensuring fewer people lose health insurance coverage and the ability to afford care when they lose their jobs, reducing the extent to which people forgo needed health care will also require lowering transmission risks during health care encounters. Though the CARES Act addressed shortages in personal protective equipment by including provisions to purchase and distribute these essential supplies (Moss et al. 2020), shortfalls are still being reported and will likely worsen with recent upticks in COVID-19 cases.9 In the Heroes Act, proposed federal policies to address these concerns include expanded workplace safety protections specific to coronavirus, including for health care facilities, and an increase in the production and supply of emergency medical supplies, including personal protective equipment.10 Providers are also ramping up protective measures for patients and 6 FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, COVID-19 RISKS staff, such as limiting the number of patients in their waiting rooms, requiring patients to wear face coverings, and screening patients for COVID-19 symptoms by phone before patients enter their offices.11 Reestablishing regular care-seeking behavior will require keeping COVID-19 case numbers low, as well as ensuring COVID-19 testing is widely available and affordable and that it produces quick results. These and other policies that make care affordable and safe to access will be critical to ensuring families, particularly those losing jobs, get the medical care they need during the pandemic. Data and Methods This brief draws on data from the first wave of the Urban Institute’s Coronavirus Tracking Survey, a nationally representative, internet-based survey of nonelderly adults designed to assess the impact of the COVID-19 pandemic on adults and their families and how those impacts change over time. A total of 4,352 adults ages 18 to 64 participated in the first wave, which was fielded May 14 through 27, 2020, with 93.1 percent of respondents completing the survey between May 14 and 20. The respondents were sampled from the 9,032 adults who participated in the most recent round of the Urban Institute’s Health Reform Monitoring Survey (HRMS), which was fielded March 25 through April 10, 2020. The HRMS sample is drawn from Ipsos’s KnowledgePanel, the nation’s largest probability- based online panel. The panel is recruited from an address-based sampling frame covering 97 percent of US households and includes households with and without internet access. Participants can take the survey in English or Spanish. The tracking survey includes an oversample of non-Hispanic Black and Hispanic HRMS participants. Survey weights adjust for unequal selection probabilities and are poststratified to the characteristics of the national nonelderly adult population based on benchmarks from the Current Population Survey and American Community Survey. The margin of sampling error, including the design effect, for the full sample of adults in the first wave of the tracking survey is plus or minus 1.9 percentage points for a 50 percent statistic at the 95 percent confidence level. The second wave of the tracking survey will be fielded in the summer of 2020. Additional information about the March/April 2020 HRMS and the questionnaires for the HRMS and first wave of the Coronavirus Tracking Survey can be found at hrms.urban.org. Notes 1 Elizabeth Hlavinka, “COVID-19 Shutters Some Private Practices,” MedPage Today, March 27, 2020, https://www.medpagetoday.com/infectiousdisease/covid19/85637; Spencer Kimball, “Doctors Face Pay Cuts, Furloughs and Supply Shortages as Coronavirus Pushes Primary Care to the Brink,” CNBC, May 25, 2020, https://www.cnbc.com/2020/05/25/coronavirus-family-doctors-face-pay-cuts-furloughs-and-supply- shortages.html; Colin Planalp, Giovann Alarcon, Lynn A. Blewett, “Coronavirus Pandemic Caused More Than 10 Million US Adults to Lose Health Insurance,” State Health Access Data Assistance Center, May 14, 2020, https://www.shadac.org/news/SHADAC_COVID19_AmeriSpeak-Survey. 2 Marshall Allen, “Unnecessary Medical Care: More Common Than You Might Imagine,” NPR, February 1, 2018, https://www.npr.org/sections/health-shots/2018/02/01/582216198/unnecessary-medical-care-more- FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, C OVID-19 RISKS 7 common-than-you-might-imagine; Austin Frakt, “Why Doctors Still Offer Treatments That May Not Help,” New York Times, August 26, 2019, https://www.nytimes.com/2019/08/26/upshot/why-doctors-still-offer- treatments-that-may-not-help.html?module=inline. 3 Philip Fisher, Tyson Barker, Alex Wagnon, Jenny Mendoza, Allison Kunerth, Becky Jaques-Hasak, Sara Weston, et al., “Health, Interrupted: Well-Child Visits Are Declining during the COVID-19 Pandemic,” Center for Translational Neuroscience at the University of Oregon, May 26, 2020, https://medium.com/rapid-ec- project/health-interrupted-a463733ce3c5; Andrew Joseph, “WHO Warns Millions of Children at Risk as COVID-19 Pandemic Disrupts Routine Vaccinations,” STAT, May 22, 2020, https://www.statnews.com/2020/05/22/who-routine-childhood-vaccinations-disrupted-coronavirus/. 4 Usha Lee McFarling, “‘Where Are All Our Patients?’: COVID Phobia Is Keeping People with Serious Heart Symptoms Away from ERs,” STAT, April 23, 2020, https://www.statnews.com/2020/04/23/coronavirus- phobia-keeping-heart-patients-away-from-er/; Will Stone and Elly Yu, “Empty ERs Worry Doctors as Heart Attack and Stroke Patients Delay Care,” U.S. News and World Report, May 8, 2020, https://www.usnews.com/news/healthiest-communities/articles/2020-05-08/empty-emergency-rooms- worry-doctors-as-heart-attack-stroke-patients-delay-care; Jack Gillum, Lisa Song, and Jeff Kao, “There’s Been a Spike in People Dying at Home in Several Cities. That Suggests Coronavirus Deaths Are Higher Than Reported,” ProPublica, April 14, 2020, https://www.propublica.org/article/theres-been-a-spike-in-people- dying-at-home-in-several-cities-that-suggests-coronavirus-deaths-are-higher-than-reported; William Feuer, “Doctors Worry the Coronavirus Is Keeping Patients Away from US Hospitals as ER Visits Drop: ‘Heart Attacks Don’t Stop,’” CNBC, April 14, 2020, https://www.cnbc.com/2020/04/14/doctors-worry-the-coronavirus-is- keeping-patients-away-from-us-hospitals-as-er-visits-drop-heart-attacks-dont-stop.html 5 “Public Poll: Emergency Care Concerns amidst COVID-19,” American College of Emergency Physicians, accessed July 5, 2020, https://www.emergencyphysicians.org/globalassets/emphysicians/all-pdfs/acep-mc- covid19-april-poll-analysis.pdf; Lydia Saad, “Americans Worry Doctor Visits Raise COVID-19 Risk,” Gallup News, April 6, 2020, https://news.gallup.com/poll/307640/americans-worry-doctor-visits-raise-covid- risk.aspx; Hamel et al. (2020); Planalp, Alarcon, and Blewett, “Coronavirus Pandemic Caused More Than 10 Million US Adults to Lose Health Insurance,” State Health Access Data Assistance Center. 6 In the May 2020 Coronavirus Tracking Survey, about two-fifths of nonelderly adults (43.4 percent) reported that someone in the family lost work or work-related income because of the coronavirus outbreak. 7 Differences in forgone care do not owe solely to differences between the characteristics of adults in families losing work or income and the characteristics of adults whose families did not lose work or income. The greater prevalence of forgone care among those losing work or income persists after accounting for differences in these groups’ demographic and socioeconomic characteristics. 8 Fisher et al., “Health, Interrupted: Well-Child Visits Are Declining during the COVID-19 Pandemic,” Center for Translational Neuroscience at the University of Oregon; Jan Hoffman, “Vaccine Rates Drop Dangerously as Parents Avoid Doctor’s Visits,” New York Times, April 23, 2020, https://www.nytimes.com/2020/04/23/health/coronavirus-measles-vaccines.html; Chloe E. Nunneley, “The Impact of COVID-19 on Infant and Child Health Care, Beyond Missed Vaccinations,” ABC News, April 29, 2020, https://abcnews.go.com/Health/impact-covid-19-infant-child-health-care-missed/story?id=70316384. 9 Lois Parshley, “Remember the N95 Mask Shortage? It’s Still a Problem,” Vox, June 17, 2020, https://www.vox.com/2020/6/17/21293021/coronavirus-n95-masks-prevent-covid-19-gloves-face-shields; Keith Reynolds, “Coronavirus: PPE Shortages Expected to Continue,” Medical Economics, June 11, 2020, https://www.medicaleconomics.com/view/coronavirus-ppe-shortages-expected-continue; Derek Hawkins, Miriam Berger, Meryl Kornfield, Brittany Shammas, Karla Adam, Hannah Knowles, Samantha Pell, and Candace Buckner, “As Coronavirus Infections Surge Nationwide, 21 States See Increase in Average Daily New Cases,” Washington Post, June 13, 2020, https://www.washingtonpost.com/nation/2020/06/13/coronavirus-live- updates-us/. 10 The Heroes Act, H.R. 6800 (2020). 11 Alan Yu, “Is It Safe Yet To Get Your Physical or a Dental Checkup?,” NPR, June 3, 2020, https://www.npr.org/sections/health-shots/2020/06/03/867505454/is-it-safe-yet-to-get-your-physical-or-a- dental-checkup. 8 FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, COVID-19 RISKS References Carroll, Aaron E. 2017. “The High Costs of Unnecessary Care.” JAMA 318 (18): 1748–49. https://doi.org/10.1001/jama.2017.16193. Garcia, Santiago, Mazen S. Albaghdadi, Perwaiz M. Meraj, Christian Schmidt, Ross Garberich, Farouc A. Jaffer, Simon Dixon, et al. 2020. “Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19 Pandemic.” Journal of the American College of Cardiology 75 (22): 2871– 72. https://doi.org/10.1016/j.jacc.2020.04.011. Hamel, Liz, Audrey Kearney, Ashley Kirzinger, Lunna Lopes, Cailey Muñana, and Mollyann Brodie. 2020. “Impact of Coronavirus on Personal Health, Economic and Food Security, and Medicaid.” In KFF Health Tracking Poll – May 2020. San Francisco: Henry J. Kaiser Family Foundation. Hartnett, Kathleen P., Aaron Kite-Powell, Jourdan DeVies, Michael A. Coletta, Tegan K. Boehmer, Jennifer Adjemian, and Adi V. Gundlapalli. 2020. “Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020.” Morbidity and Mortality Weekly Report 69 (23): 699–704. http://dx.doi.org/10.15585/mmwr.mm6923e1. Jiang, John (Xuefeng), Ge Bai, Lovisa Gustafsson, and Gerard Anderson. 2020. “Canary in a Coal Mine? A Look at Initial Data on COVID-19’s Impact on US Hospitals.” New York: Commonwealth Fund. Karpman, Michael, Stephen Zuckerman, Dulce Gonzalez, and Genevieve M. Kenney. 2020. “The COVID-19 Pandemic Is Straining Families’ Abilities to Afford Basic Needs: Low-Income and Hispanic Families the Hardest Hit.” Washington, DC: Urban Institute. Karpman, Michael, Stephen Zuckerman, and Graeme Peterson. 2020. “Adults in Families Losing Jobs during the Pandemic Also Lost Employer-Sponsored Health Insurance.” Washington, DC: Urban Institute. Mehrotra, Ateev, Michael Chernew, David Linetsky, Hilary Hatch, and David Cutler. 2020. “The Impact of the COVID-19 Pandemic on Outpatient Visits: Practices Are Adapting to the New Normal.” New York: Commonwealth Fund. Mehrotra, Ateev, and Allan Prochazka. 2015. “Improving Value in Health Care — Against the Annual Physical.” New England Journal of Medicine 373:1485–87. https://doi.org/10.1056/NEJMp1507485. Moss, Kellie, Adam Wexler, Lindsey Dawson, Michelle Long, Jennifer Kates, Juliette Cubanski, MaryBeth Musumeci, et al. 2020. “The Coronavirus Aid, Relief, and Economic Security Act: Summary of Key Health Provisions.” San Francisco: Henry J. Kaiser Family Foundation. Santoli, Jeanne M., Megan C. Lindley, Malini B. DeSilva, Elyse O. Kharbanda, Matthew F. Daley, Lisa Galloway, Juliane Gee, et al. 2020. “Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020.” Morbidity and Mortality Weekly Report 69:591–93. Shrank, William, H., Teresa L. Rogstad, and Natasha Parekh. 2019. “Waste in the US Health Care System: Estimated Costs and Potential for Savings.” JAMA 322 (15): 1501–09. https://doi.org/10.1001/jama.2019.13978. Weinstein, James N, Geller Amy, Negussie Yamrot, and Baciu, Alina, editors. Communities in Action: Pathways to Health Equity. The National Academies Press. FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, COVID-19 RISKS 9 About the Authors Dulce Gonzalez is a research analyst in the Health Policy Center at the Urban Institute. Before joining Urban, she interned at the Georgetown University Center for Children and Families, where she conducted qualitative and quantitative analyses on Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act. Gonzalez has also worked at the nonprofit organization Maternal and Child Health Access, where she evaluated health and well-being outcomes for women in the Welcome Baby Program, a perinatal home visiting program. She received her MPP from Georgetown University. Stephen Zuckerman is a senior fellow and vice president for health policy at the Urban Institute. He has studied health economics and health policy for 30 years and is a national expert on Medicare and Medicaid physician payment, including how payments affect enrollee access to care and the volume of services they receive. He is currently examining how payment and delivery system reforms can affect the availability of primary care services and studying the implementation and impact of the Affordable Care Act. Before joining Urban, Zuckerman worked at the American Medical Association’s Center for Health Policy Research. He received his PhD in economics from Columbia University. Genevieve M. Kenney is a senior fellow and vice president for health policy at the Urban Institute. She has conducted policy research for more than 25 years and is a nationally renowned expert on Medicaid, the Children’s Health Insurance Program (CHIP), and broader health insurance coverage and health issues facing low-income children and families. Kenney has led several Medicaid and CHIP evaluations and published more than 100 peer-reviewed journal articles and scores of briefs on insurance coverage, access to care, and related outcomes for low-income children, pregnant women, and other adults. In her current research, she is examining the implications of the Affordable Care Act, how access to primary care varies across states and insurance groups, and emerging policy questions related to Medicaid and CHIP. She received a master’s degree in statistics and a doctoral degree in economics from the University of Michigan. Michael Karpman is a senior research associate in the Health Policy Center. His work focuses primarily on the implications of the Affordable Care Act, including quantitative analysis related to health insurance coverage, access to and affordability of health care, use of health care services, and health status. His work includes overseeing and analyzing data from the Urban Institute’s Health Reform Monitoring Survey and Well-Being and Basic Needs Survey. Before joining Urban in 2013, Karpman was a senior associate at the National League of Cities Institute for Youth, Education, and Families. He received his MPP from Georgetown University. 10 FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, COVID-19 RISKS Acknowledgments This brief was funded by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute’s funding principles is available at urban.org/fundingprinciples. The authors gratefully acknowledge helpful comments on earlier drafts from Stacey McMorrow, and thank Rachel Kenney for her careful editing. ABOUT THE URBAN INST ITUTE The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people’s lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness 500 L’Enfant Plaza SW and enhance the well-being of people and places. Washington, DC 20024 Copyright © July 2020. Urban Institute. Permission is granted for reproduction of www.urban.org this file, with attribution to the Urban Institute. FAMILIES LOSING WORK AVOIDED HEALTH CARE BECAUSE OF COSTS, C OVID-19 RISKS 11