HEALTH POLICY CENTER 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. Delayed and Forgone Health Care for Nonelderly Adults during the COVID-19 Pandemic Findings from the September 11–28 Coronavirus Tracking Survey Dulce Gonzalez, Michael Karpman, Genevieve M. Kenney, and Stephen Zuckerman February 2021 The COVID-19 pandemic has disrupted health care in an unprecedented way, leading some patients to postpone or forgo care (Czeisler et al. 2020).1 Visits to primary care physicians, emergency rooms, and other health care providers fell as providers scaled back their operations and patients curbed their health care use because of the pandemic (Garcia et al. 2020; Hartnett et al. 2020; Jiang et al. 2020; Mast and Munoz del Rio 2020; Mehrotra et al. 2020; Santoli et al. 2020). Most health care providers have new safety protocols in place2 and have seen visits rebound since the start of the pandemic (Mehrotra et al. 2020). However, significant numbers of patients continue avoiding care because they fear exposure to the novel coronavirus (Morning Consult and American College of Emergency Physicians 2020),3 and reduced patient volumes are leading some physicians to close their practices for financial reasons.4 Though some missed care may have been of low value or unnecessary, physicians report concern over unmet needs for care, particularly for people with chronic health conditions, whose health can deteriorate rapidly without careful monitoring and treatment.5 Mortality data suggest the pandemic has caused a surge in excess deaths from conditions such as diabetes, dementia, hypertension, heart disease, and stroke, and a record number of drug overdose deaths occurred in the 12 months ending in May 2020 (Woolf et al. 2020).6 These events underscore the importance of ensuring people with chronic physical and behavioral health conditions continue to access the care they need during the public health crisis and beyond. Using data from the most recent wave of the Coronavirus Tracking Survey, a nationally representative survey of nonelderly adults conducted September 11 through 28, 2020, we examine delayed or forgone health care during the pandemic among adults ages 18 to 64. We examine experiences with nine types of health care services and assess patterns by race/ethnicity, income, and the presence of physical and mental health conditions, including conditions associated with elevated risk for severe illness from COVID-19.7 Our analysis focuses on reported instances of delayed or forgone care resulting from patients’ and providers’ efforts to prevent transmission of the virus: (1) care respondents did not receive because they were worried about exposure to the coronavirus and (2) care they did not receive because a health care provider limited services because of the coronavirus outbreak. Adults who reported not getting one or more types of care were asked whether they eventually got care (delayed care) or had still not gotten it at the time of the survey (forgone care). Because reported impacts of delaying care did not meaningfully differ from reported impacts of not getting care at all, we present estimates of delayed or forgone care in combination. In this analysis, we do not focus on delayed or forgone care for other reasons, such as lack of insurance, costs or affordability, preexisting provider shortages, or administrative barriers (e.g., prior authorization).8 Though several surveys have quantified the prevalence of delayed or forgone care during the pandemic,9 few have explored the extent for individual types of care, the experiences of adults with chronic health conditions (Czeisler et al. 2020), or how people say delaying or not getting care has affected their health, ability to work, and other routine activities. We find the following: ◼ As of September 2020, more than one in three adults (36.0 percent) reported delaying or forgoing health care because of worry about exposure to the coronavirus or because a health care provider limited services during the pandemic. Black adults were more likely than white or Hispanic/Latinxi adults to report delaying or forgoing care (39.7 versus 34.3 percent and 35.5 percent) and more likely to report delaying or forgoing multiple types of care (28.5 versus 21.1 percent and 22.3 percent). ◼ About 4 in 10 adults with one or more chronic health conditions (40.7 percent) and more than half of adults with both a physical and mental health condition (56.3 percent) reported delaying or forgoing health care because of the pandemic. About 43.8 percent of the latter group delayed or went without multiple types of care. Adults with mental health conditions were at particularly high risk of delaying or forgoing care (52.0 percent). ◼ Dental care was the most common type of care adults delayed or did not receive because of the pandemic (25.3 percent of adults reported going without or delaying dental care), followed i We use “Hispanic/Latinx” throughout this brief to reflect the different ways in which people self-identify. The US Census Bureau uses the term “Hispanic.” The terms “white” and “Black” refer to adults who do not identify as Hispanic or Latinx. 2 DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC by seeing a general doctor or specialist (20.6 percent) or receiving preventive health screenings or medical tests (15.5 percent). ◼ More than three-quarters of adults with delayed or forgone health care (76 percent) had one or more chronic health conditions, such as hypertension, diabetes, respiratory illness, heart disease, cancer, kidney disease, and mental health disorders. ◼ Among adults reporting delayed or forgone health care, almost one in three (32.6 percent) reported doing so worsened one or more of their health conditions or limited their abilities to work or perform other daily activities. These results demonstrate the importance of addressing health issues that have not been attended to during the pandemic. Failing to do so could exacerbate health inequities by race and income and exacerbate health problems broadly, particularly among adults with mental health conditions. Results As of September 2020, more than one in three adults (36.0 percent) reported delaying or forgoing health care because of worry about exposure to the coronavirus or because a health care provider limited services during the pandemic. Black adults were more likely than white or Hispanic/Latinx adults to report delaying or forgoing care (39.7 versus 34.3 percent and 35.5 percent) and more likely to report delaying or forgoing multiple types of care (28.5 versus 21.1 percent and 22.3 percent). Overall, 36.0 percent of nonelderly adults delayed or not did not get at least one type of health care during the pandemic because of worry about exposure to coronavirus or because a provider limited services because of the pandemic. Nearly 1 in 4 (23.1 percent) adults reported delaying or forgoing multiple types of care for these reasons (figure 1). More than 1 in 4 (26.2 percent) reported delaying or forgoing care because of worries about exposure to the coronavirus, and more than 1 in 6 (17.2 percent) delayed or went without multiple types of care for this reason. Similar shares of adults delayed or did not get care because of providers limiting services: 23.2 percent delayed or did not get least one type of needed care and 12.3 percent delayed or did not get multiple types of care for this reason. More than 1 in 10 (11.8 percent) adults reported only delaying care, and nearly 1 in 4 (24.1 percent) did not get at least one type of care for pandemic-related reasons (data not shown). DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC 3 FIGURE 1 Share of Adults Ages 18 to 64 Who Reported Delaying or Forgoing Health Care Because of the Pandemic, September 2020 Delayed or did not get at least one type of care Delayed or did not get multiple types of care 36.0% 26.2% 23.2% 23.1% 17.2% 12.3% Worry about coronavirus exposure Provider limited services Worry about exposure or provider limited services Reason for delaying or not getting care URBAN INSTITUTE Source: Urban Institute Coronavirus Tracking Survey, wave 2, conducted September 11 through 28, 2020. As noted, 39.7 percent of Black adults reported delaying or forgoing one or more types of care because they worried about exposure to the coronavirus or their providers had limited services because of the pandemic (figure 2). This share was higher than that for both white (34.3 percent) and Hispanic/Latinx (35.5 percent) adults. Black adults were also more likely to report delaying or forgoing multiple types of care (28.5 percent) than white (21.1 percent) and Hispanic/Latinx adults (22.3 percent). Adults with family incomes below 250 percent of the federal poverty level were more likely to report delaying or forgoing multiple types of care than adults with higher incomes (26.6 percent versus 20.3 percent). Differences in delayed or forgone care by race/ethnicity and income were primarily driven by differences in avoiding care because of concerns about exposure to the virus: Black adults were more likely than white and Hispanic/Latinx adults to delay or forgo care for this reason, and adults with lower incomes were more likely to delay or forgo care for this reason than those with higher incomes (data not shown). We did not find statistically significant differences by race or ethnicity and income in delayed or forgone care because providers limited their services. 4 DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC FIGURE 2 Share of Adults Ages 18 to 64 Who Reported Delaying or Forgoing Health Care Because of the Pandemic, by Race/Ethnicity and Family Income, September 2020 Delayed or did not get at least one type of care Delayed or did not get multiple types of care 39.7%* 37.0% 34.3% 35.5%^ 35.2% 28.5%*** 26.6% 21.1% 22.3%^^ 20.3%+++ White Black Hispanic/Latinx Below 250% of FPL 250% of FPL or higher Race/ethnicity Family income URBAN INSTITUTE Source: Urban Institute Coronavirus Tracking Survey, wave 2, conducted September 11 through 28, 2020. Notes: FPL = federal poverty level. Estimates are not shown for non-Hispanic/Latinx adults who are not Black or white or are more than one race. Delayed or forgone health care is care not received because of worry about exposure to the coronavirus or because health care providers limited services because of the pandemic. */**/*** Estimate differs significantly from white adults at the 0.10/0.05/0.01 level, using two-tailed tests. ^/^^/^^^ Estimate differs significantly from Black adults at the 0.10/0.05/0.01 level, using two-tailed tests. +/++/+++ Estimate differs significantly from adults with incomes below 250% of FPL at the 0.10/0.05/0.01 level, using two- tailed tests. About 4 in 10 adults with one or more chronic health conditions (40.7 percent) and more than half of adults with both a physical and mental health condition (56.3 percent) reported delaying or forgoing health care because of the pandemic. About 43.8 percent of the latter group delayed or went without multiple types of care. Adults with mental health conditions were at particularly high risk of delaying or forgoing care (52.0 percent). As shown in figure 3, adults with at least one chronic health condition were more likely than adults with no chronic conditions to have delayed or forgone care because of the pandemic (40.7 percent versus 26.4 percent). This pattern may reflect greater health care needs, heightened concerns about exposure to the coronavirus, or greater difficulty finding available providers among those with chronic health conditions. A person’s likelihood of delaying or forgoing care increased with their number of chronic conditions: 32.7 percent of adults with one chronic condition and 45.5 percent of adults with multiple chronic conditions delayed or went without one or more types of care (data not shown). Adults with both a physical and mental health condition reported delaying or forgoing care at particularly high rates; more than half (56.3 percent) delayed or went without one or more types of DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC 5 care because of the pandemic, and 4 in 10 (43.8 percent) delayed or did not get multiple types of care. Though the presence of both physical and mental health conditions was associated with higher rates of delaying or forgoing needed health care, such rates were especially high among those with mental health conditions (52.0 percent). FIGURE 3 Share of Adults Ages 18 to 64 Who Reported Delaying or Forgoing Health Care Because of the Pandemic, by Presence of Chronic Health Conditions, September 2020 Delayed or did not get at least one type of care Delayed or did not get multiple types of care 56.3%*** 52.0%*** 43.8%*** 40.7%*** 40.6%*** 38.3%*** 26.4% 27.2%*** 27.5%*** 14.7% No health condition Any condition Any physical health Any mental health Both physical and condition condition mental health condition URBAN INSTITUTE Source: Urban Institute Coronavirus Tracking Survey, wave 2, conducted September 11 through 28, 2020. Notes: Delayed or forgone health care is care not received because of worry about exposure to the coronavirus or because health care providers limited services because of the pandemic. */**/*** Estimate differs significantly from adults without chronic health conditions at the 0.10/0.05/0.01 level, using two-tailed tests. Dental care was the most common type of care adults delayed or did not receive because of the pandemic (25.3 percent), followed by seeing a general doctor or specialist (20.6 percent) or receiving preventive health screenings or medical tests (15.5 percent). As noted above and in figure 4, dental care was the most common type of care adults delayed or did not receive because of the pandemic. Adults also delayed or did not get other types of care that may be important for managing chronic conditions and detecting and preventing disease: One in five (20.6 percent) reported not seeing a general doctor or specialist. Another 15.5 percent had a delayed or unmet need for preventive health screenings or medical tests, and 11.5 percent delayed or went without treatment or follow-up care. Some adults also reported not going to hospitals (10.1 percent) and delaying or not getting mental health care or counseling (6.0 percent), prescription drugs (5.6 percent), or treatment or counseling for alcohol or drug use (2.0 percent). 6 DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC FIGURE 4 Types of Health Care Adults Ages 18 to 64 Delayed or Did Not Get Because of the Pandemic, September 2020 Dental care 25.3% A general doctor or specialist visit 20.6% Preventive health screenings or medical tests 15.5% Treatment or follow-up care 11.5% Hospital visits 10.1% Mental health care or counseling 6.0% Prescription drugs 5.6% Treatment or counseling for alcohol or drug use 2.0% Some other type of medical care 0.8% URBAN INSTITUTE Source: Urban Institute Coronavirus Tracking Survey, wave 2, conducted September 11 through 28, 2020. Notes: Delayed or forgone health care is care not received because of worry about exposure to the coronavirus or because health care providers limited services because of the pandemic. More than three-quarters of adults with delayed or forgone health care (76.0 percent) had one or more chronic health conditions, such as hypertension, diabetes, respiratory illness, heart disease, cancer, and mental health disorders. Those who delayed or did not get health care because of the pandemic were more than 15 percentage points more likely than those who did not delay or go without care to have a chronic condition (76.0 percent versus 62.3 percent; data not shown). As shown in table 1, the physical health conditions most commonly reported by adults with delayed or forgone care included obesity, high cholesterol, high blood pressure, arthritis, diabetes, asthma, chronic obstructive pulmonary disease and other respiratory illnesses, heart disease, and cancer. Mental health conditions such as anxiety and depressive disorders were twice as common among adults with delayed or forgone care as among adults who did not delay or go without care (36.4 percent versus 18.9 percent; data not shown). DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC 7 TABLE 1 Presence of Chronic Health Conditions among Adults Ages 18 to 64 Delaying or Forgoing Health Care, September 2020 Chronic health conditions Percent Has a chronic health condition 76.0 Has a physical health condition 67.9 Obesity 34.7 High cholesterol 29.4 Hypertension 28.9 Some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia 20.5 Asthma 13.6 Diabetes (excluding gestational or prediabetes) 10.1 Chronic obstructive pulmonary disease, emphysema, or chronic bronchitis 4.9 Coronary heart disease, angina, heart attack, or other heart condition 4.9 Cancer 4.1 Chronic kidney disease 3.2 Stroke 2.0 Liver disease, including cirrhosis 2.0 Dementia, including Alzheimer's disease 0.9 Cystic or pulmonary fibrosis 0.8 Sickle cell disease or thalassemia 0.4 Has a mental health condition 36.4 Any type of anxiety disorder 28.4 Any type of depression 26.4 Any other type of mental health condition 8.5 Source: Urban Institute Coronavirus Tracking Survey, wave 2, conducted September 11 through 28, 2020. Notes: N = 1,510 adults. Delayed or forgone health care is care not received because of worry about exposure to the coronavirus or because health care providers limited services because of the pandemic. Among adults reporting delayed or forgone health care, almost one in three (32.6 percent) reported doing so worsened one or more of their health conditions or limited their abilities to work or perform other daily activities. Figure 5 shows adults’ reported impacts of delaying or forgoing care. An estimated 23.2 percent of these adults reported going without or delaying care worsened a health condition, 15.2 percent reported it limited their ability to work, and 21.0 percent reported it limited their ability to do other daily activities. Adults who reported never getting at least one type of care were more likely to report experiencing these negative consequences than adults who only delayed care (35.2 percent versus 27.3 percent); they were more likely to report doing so worsened one of their health conditions (26.3 percent versus 17.1 percent) and limited their ability to do other daily activities (22.8 percent versus 17.4 percent). For adults who delayed or did without multiple types of care, we cannot link consequences to specific services. When we separate adults who only delayed or went without dental care, we find very few of these adults reported one or more of these adverse consequences. This suggests the consequences for health, work, and other daily activities differ depending on the type of care delayed or missed. We do not show these estimates because of sample size limitations. 8 DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC FIGURE 5 Reported Impact of Delayed and Forgone Health Care among Adults Ages 18 to 64, September 2020 Any impact Worsened one or more health conditions Limited ability to work Limited ability to do other daily activities 35.2%** 32.6% 27.3% 26.3%*** 23.2% 22.8%** 21.0% 17.1% 17.4% 15.2% 16.2% 13.0% Any delayed or forgone care Delayed care only Any forgone care URBAN INSTITUTE Source: Urban Institute Coronavirus Tracking Survey, wave 2, conducted September 11 through 28, 2020. Notes: Delayed or forgone health care is care not received because of worry about exposure to the coronavirus or because health care providers limited services because of the pandemic. */**/*** Estimate differs significantly from adults who reported only delaying care because of the pandemic at the 0.10/0.05/0.01 level, using two-tailed tests. Discussion We find that, as of September 2020, 36 percent of nonelderly adults had delayed or gone without health care because of worry about exposure to the coronavirus or because a health care provider limited services because of the pandemic. Black adults reported forgoing or delaying care because of the pandemic at higher rates than white and Hispanic/Latinx adults, which suggests the pandemic is exacerbating existing racial health inequities. In addition, adults reported delaying or forgoing care that can be important for managing chronic conditions and detecting and preventing disease, such as general doctor or specialist visits, preventive health screenings and medical tests, and follow-up care. We find adults with chronic conditions, particularly those with a mental health condition, were more likely to have delayed or gone without care than those without chronic health conditions. These patterns may reflect not only greater needs for care among people with chronic conditions but their greater fear of exposure to the coronavirus or greater difficulty finding providers. More than three- quarters of adults who delayed or did not get care because of the pandemic reported at least one of the chronic health conditions we examined, including conditions that place people at high risk for severe illness from COVID-19. Finally, nearly one in three adults who delayed or went without care reported it negatively affected their health, ability to work, or ability to perform other daily activities, DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC 9 highlighting the detrimental ripple effects of delaying or forgoing care on overall health, functioning, and well-being. Tackling unmet health care needs requires effectively assuaging fears about exposure to the coronavirus. Patients must be reassured that providers’ safety precautions follow public health guidelines, and that these precautions effectively prevent transmission in offices, clinics, and hospitals. More data showing health care settings are not common sources of transmission and better communication with the public to promote the importance of seeking needed and routine care are also needed. Children have been missing care during the pandemic (Gonzalez et al. 2021), and Medicaid has been using available resources and promising strategies to address this (McMorrow et al. 2020). Similar strategies could be employed for adults. For example, Medicaid managed-care organizations could target outreach and case management services to patients who have chronic health issues but have been missing out on care or not getting recommended screenings. Our findings also highlight the importance of continued efforts to reduce COVID-19 transmission and promote vaccination to reduce patients’ exposure to the virus. With providers closing or limiting in-person services during the pandemic, our findings also underscore the importance of supporting telehealth, chronic disease self-management, and care coordination among providers. People with mental health conditions appear to be at particularly elevated risk of not getting care and could benefit from facilitated access to telehealth services. Telehealth use expanded greatly over the first six months of the pandemic, but not uniformly across the population. Another analysis of September 2020 Coronavirus Tracking Survey data showed that Black and Hispanic/Latinx adults were more likely than white adults to report having wanted a telehealth visit but not received one since the pandemic began, and that difficulties getting a telehealth visit were also more common among adults who were in poorer health or had chronic health conditions (Smith and Blavin 2021).10 Much work remains to ensure all patients have equitable access to remote care during and after the pandemic. Though this study does not focus on cost, it will likely be a barrier for many people who will be ready to return to health care settings when they feel safe. The pandemic has led to widespread negative economic impacts, and many of those most affected by the recession have also delayed or forgone care because of cost or COVID-19 concerns (Gonzalez et al. 2020). Enhanced efforts are needed to ensure all people have affordable insurance and access to care during and after the pandemic. Full recovery will also require shoring up provider capacity as demand for health care returns, including making additional funding available to ensure providers facing pandemic-related financial hardship can keep their practices open. And, health insurance coverage alone is not enough; policymakers will need to address other long-standing concerns like material hardship, financial instability, and language and cultural barriers that prevent even those with health insurance from equitable access to needed care (Berkowitz, Cené, and Chatterjee 2020). 10 DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC Data and Methods This brief uses data from the second wave of the Urban Institute’s Coronavirus Tracking Survey, a nationally representative internet-based survey of nonelderly adults designed to assess how the COVID-19 pandemic is affecting adults and their families and how those effects change over time. A total of 4,007 adults ages 18 to 64 participated in the second wave, which was fielded September 11 through 28, 2020; 91 percent of respondents completed the survey between September 11 and 17. The first wave of the tracking survey was fielded May 14 through 27. Respondents for both waves were sampled from the 9,032 adults who participated in the most recent round of the 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 Coronavirus Tracking Survey includes an oversample of Black and Hispanic/Latinx 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. We also adjust the September tracking survey weights to address differential nonresponse among participants in the March/April HRMS. Because nonresponse in the September survey is greater among HRMS participants experiencing negative employment effects and material hardship during the pandemic and these effects differ based on demographic characteristics, we adjust the weights so work status and employment and hardship outcomes reported in March/April among the September sample are consistent with the outcomes reported among the full March/April HRMS sample both overall and within key demographic subgroups. These adjustments make the September tracking survey sample more representative of the sample initially drawn in March/April and mitigate nonresponse bias in estimated changes over time in the pandemic’s effects. The margin of sampling error, including the design effect, for the full sample of adults in the second wave of the tracking survey is plus or minus 2.0 percentage points for a 50 percent statistic at the 95 percent confidence level. Additional information about the March/April 2020 HRMS and the questionnaires for the HRMS and first and second waves of the Coronavirus Tracking Survey can be found at hrms.urban.org. Analytic Approach We asked survey respondents two questions about whether they did not get care because of the pandemic. The first asked whether there was ever a time when respondents needed several types of health care but did not get them because they were worried about being exposed to the coronavirus. The second question asked whether there was ever a time when respondents needed several types of health care but did not get them because a health care provider limited services because of the pandemic. Each question asked about the following types of care: prescription drugs; a general doctor DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC 11 or specialist visit; going to a hospital; preventive health screenings or medical tests; treatment or follow-up care; dental care; mental health care or counseling; treatment or counseling for alcohol or drug use; or some other type of medical care. Those who reported not getting one or more types of care were asked whether they eventually got care (delayed care) or had still not gotten it at the time of the survey (forgone care). We assessed differences in delayed and forgone care based on whether respondents were ever told by a doctor or other health professional that they had any of several chronic health conditions. We asked about conditions commonly included in federal health surveys and conditions the Centers for Disease Control and Prevention has identified as increasing a person’s risk of moderate or severe illness from contracting COVID-19.11 We also asked about height and weight to construct a measure of body mass index to define obesity. Notes 1 “Reduced Access to Care – Household Pulse Survey,” Centers for Disease Control and Prevention, National Center for Health Statistics, January 6, 2021, https://www.cdc.gov/nchs/covid19/pulse/reduced-access-to- care.htm; Elizabeth Lawrence, “Nearly Half of Americans Delayed Medical Care Due to Pandemic,” Kaiser Health News, May 27, 2020, https://khn.org/news/nearly-half-of-americans-delayed-medical-care-due-to- pandemic/; “The Impact of the Coronavirus on Households across America,” Robert Wood Johnson Foundation, accessed February 4, 2021, https://www.rwjf.org/en/library/research/2020/09/the-impact-of- coronavirus-on-households-across-america.html; and “KFF Health Tracking Poll – October 2020,” Henry J. Kaiser Family Foundation, accessed January 26, 2021, http://files.kff.org/attachment/Topline-KFF-Health- Tracking-Poll-October-2020.pdf. 2 “COVID-19: A Physician Guide to Keeping Your Practice Open,” American Medical Association, December 16, 2020, https://www.ama-assn.org/delivering-care/public-health/covid-19-physician-guide-keeping-your- practice-open. 3 American Heart Association, “Fueled by COVID-19 Fears, Approximately Half of Hispanics and Black Americans Would Fear Going to the Hospital If Experiencing Symptoms of a Heart Attack or Stroke,” news release, July 23, 2020, https://newsroom.heart.org/news/fueled-by-covid-19-fears-approximately-half-of- hispanics-and-black-americans-would-fear-going-to-the-hospital-if-experiencing-symptoms-of-a-heart-attack- or-stroke; 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/; and Will Stone and Elly Yu, “Empty ERs Worry Doctors as Heart Attack and Stroke Patients Delay Care,” US News and World Report, May 8, 2020, https://www.usnews.com/news/healthiest-communities/articles/2020-05-08/empty-emergency- roomsworry-doctors-as-heart-attack-stroke-patients-delay-care. 4 “Physician Financial Health Survey 2.0,” California Medical Association, accessed January 25, 2021, https://www.cmadocs.org/covid-19/survey; “The Physicians Foundation 2020 Survey of America’s Physicians: COVID-19 Impact Edition,” Physicians Foundation, accessed January 25, 2021, https://physiciansfoundation.org/wp-content/uploads/2020/12/2020-Survey-of-Americas-Physicians_Exec- Summary.pdf; Elizabeth Hlavinka, “COVID-19 Shutters Some Private Practices,” MedPage Today, March 27, 2020, https://www.medpagetoday.com/infectiousdisease/covid19/85637; and 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- supplyshortages.html. 5 Heather Landi, “Doctors Report Patients' Health Declining Due to Delayed or Inaccessible Care during COVID- 19 Pandemic,” Fierce Healthcare, November 19, 2020, https://www.fiercehealthcare.com/practices/patients- health-declining-due-to-delayed-or-inaccessible-care-during-covid-19-pandemic; Allison H. Oakes and Jodi B. 12 DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC Segal, “The COVID-19 Pandemic Can Help Us Understand Low-Value Health Care,” Health Affairs Blog, October 27, 2020, https://www.healthaffairs.org/do/10.1377/hblog20201023.522078/full/; and Gina Kolata, “Amid Pandemic, Scientists Reassess Routine Medical Care,” New York Times, December 12, 2020, https://www.nytimes.com/2020/12/12/health/pandemic-routine-medical-care.html. 6 Denise Lu, “2020 Was Especially Deadly. Covid Wasn’t the Only Culprit,” New York Times, December 13, 2020, https://www.nytimes.com/interactive/2020/12/13/us/deaths-covid-other-causes.html; and Centers for Disease Control and Prevention, “Overdose Deaths Accelerating during COVID-19,” news release, December 17, 2020, https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html. 7 For more information about how chronic conditions were defined, see note 11. 8 An Urban Institute study in May 2020 found greater rates of missed care among adults who had lost work or income because of the pandemic. See Gonzalez and colleagues (2020). 9 See the list of surveys in note 1 above. 10 David Velasquez and Ateev Mehrotra, “Ensuring the Growth of Telehealth during COVID-19 Does Not Exacerbate Disparities in Care,” Health Affairs Blog, May 8, 2020, https://www.healthaffairs.org/do/10.1377/hblog20200505.591306/full/. 11 Physical health conditions in our analysis include obesity; high cholesterol; hypertension; some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia; asthma; diabetes; chronic obstructive pulmonary disease, emphysema, or chronic bronchitis; coronary heart disease, angina, heart attack, or other heart condition; cancer; chronic kidney disease; stroke; liver disease; dementia; cystic fibrosis or pulmonary fibrosis; and sickle cell disease or thalassemia. Mental health conditions include anxiety disorders (such as generalized anxiety disorder, social anxiety disorder, panic disorder, post-traumatic stress disorder, obsessive-compulsive disorder, or phobias); any type of depression (such as major depressive disorder, bipolar disorder, or dysthymia); and any other type of mental health condition. This list is based on conditions included in the National Health Interview Survey and Behavioral Risk Factor Surveillance System or conditions that place people at greater risk of illness from COVID-19; see “Certain Medical Conditions and Risk for Severe COVID-19 Illness,” Centers for Disease Control and Prevention, updated December 29, 2020, https://www.cdc.gov/coronavirus/2019-ncov/need- extra-precautions/people-with-medical-conditions.html. References Berkowitz, Seth A., Crystal Wiley Cené, and Avik Chatterjee. 2020. “COVID-19 and Health Equity — Time to Think Big.” New England Journal of Medicine 383:e76. https://doi.org/10.1056/NEJMp2021209. Czeisler, Mark É., Kristy Marynak, Kristie E. N. Clarke, Zainab Salah, Iju Shakya, JoAnn M. Thierry, Nida Ali, et al. 2020. “Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns – United States, June 2020.” Morbidity and Mortality Weekly Report 69 (36): 1250–57. https://doi.org/10.15585/mmwr.mm6936a4. Garcia, Santiago, Mazen S. Albaghdadi, Perwaiz M. Meraj, Christian Schmidt, Ross Garbeich, 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 (April 2020).” Journal of the American College of Cardiology 75 (22): 2871–72. https://doi.org/10.1016/j.jacc.2020.04.011. Gonzalez, Dulce, Michael Karpman, Genevieve M. Kenney, and Stephen Zuckerman. 2021. “Delayed and Forgone Health Care for Children during the COVID-19 Pandemic.” Washington, DC: Urban Institute. Gonzalez, Dulce, Stephen Zuckerman, Genevieve M. Kenney, and Michael Karpman. 2020. “Almost Half of Adults in Families Losing Work during the Pandemic Avoided Health Care Because of Costs or COVID-19 Concerns.” Washington, DC: Urban Institute. Hartnett, Kathleen P., Aaron Kite-Powell, Jourdan DeVies, Michael A. Coletta, Tegan K. Boehmer, Jennifer Adjemian, Adi V. Gundlapalli. 2020. “Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020 (June 2020).” Morbidity and Mortality Weekly Report 69 (23): 699–704. http://dx.doi.org/10.15585/mmwr.mm6923e1. DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC 13 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. Mast, Christopher, and Alejandro Munoz del Rio. 2020. “Delayed Cancer Screenings—A Second Look.” Verona, WI: Epic Health Research Network. McMorrow, Stacey, Dulce Gonzalez, Clara Alvarez Caraveo, and Genevieve M. Kenney. 2020. “Urgent Action Needed to Address Children’s Unmet Health Care Needs during the Pandemic.” 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. Morning Consult and American College of Emergency Physicians. 2020. American College of Physicians COVID-19. Washington, DC: Morning Consult and American College of Emergency Physicians. Santoli, Jeanne M., Megan C. Lindley, Malini B. DaSilva, Elyse O. Kharbanda, Matthew F. Daley, Lisa Galloway, Julienne 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 (19): 591–93. http://dx.doi.org/10.15585/mmwr.mm6919e2. Smith, Laura, and Fredric Blavin. 2021. “One in Three Adults Used Telehealth during the First Six Months of the Pandemic, but Unmet Needs for Care Persisted.” Washington, DC: Urban Institute. Woolf, Steven H., Derek A. Chapman, Roy T. Sabo, Daniel M. Weinberger, and La-toya Hill. 2020. “Excess Deaths from COVID-19 and Other Causes, March–April 2020.” JAMA 324 (5): 510–13. https://doi.org/10.1001/jama.2020.11787. 14 DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC About the Authors Dulce Gonzalez is a research associate 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. 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. 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, 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. 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. DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC 15 Acknowledgments This brief was funded by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. 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 INSTITUTE 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 © February 2021. Urban Institute. Permission is granted for www.urban.org reproduction of this file, with attribution to the Urban Institute. 16 DELAYED AND FORGONE CARE FOR ADULTS DURING THE COVID -19 PANDEMIC