Nearly 540,000 North Carolinians have filed claims for unemployment-insurance benefits in less than a month, a somber and record ripple effect from the COVID-19 pandemic.
A significant number of applicants have seldom, if ever, been without employer health-insurance coverage in their work careers.
Some worked for an employer offering a high-deductible plan with premiums so expensive they could not afford coverage even at full pay, much less after an hourly wage cut.
Others had no health insurance at all, particularly in the leisure, hospitality and retail sectors.
Even though some employers have pledged to keep furloughed employees on their health plans, the longer the stay-at-home and nonessential business orders are in place, the more likely the workers could be dropped from coverage.
If national trends hold true in North Carolina, about 20% of newly unemployed individuals fit into one of those categories, according to an April 2 report from the Economic Policy Institute.
Zagros Madjd-Sadjadi, an economics professor at Winston-Salem State University, cautions that he expects "in April that a lot of special leaves granted by employers will start to run out."
"If the employers cannot quickly access government loans and grants, they will be forced into mass layoffs now that the majority of the economy has been shuttered or at least greatly curtailed due to the governor's stay-at-home order," Madjd-Sadjadi said.
For people who have lost employer-sponsored coverage, the simplest solution is to check to see if they can be added to their spouse or significant other's employer-sponsored coverage as a qualifying life event similar to getting married.
People younger than 26 may be allowed to be added to or returned to their parents' employer-sponsored coverage.
The most-known health-insurance option for the newly unemployed is COBRA, which allows a person to continue to receive the group health benefits their employer provided, but in addition to their regular monthly premiums, they have to pay the employer' share as well.
For unemployed individuals who aren't offered or can't afford the COBRA option, there are three primary alternatives for health coverage.
One is enrolling through a one-time exemption into the federal insurance marketplace, wwwhealthcare.gov, that was established in the Affordable Care Act, also known as "Obamacare."
That site annually enrolls individuals for a six-week period from early November through mid-December.
But enrollment is permitted for a short window - typically 60 days - after an individual loses employer health coverage as part of being laid off or their job ends. That's considered as a qualifying event.
The marketplace can be accessed through most health insurers, such as Blue Cross and Blue Shield of North Carolina and UnitedHealthcare in North Carolina.
There's a slight catch: Applicants currently are required to provide documentation of their eligibility for a special individual enrollment period and whether they qualify for subsidies to lower their premium costs.
"If you are employed and had insurance through your employer, and you have lost your job and lost that insurance coming in, now you do have an enrollment period where you can enroll in the individual exchanges for the Affordable Care Act," U.S. Health Secretary Alex Azar said. "That is existing law."
There's also an enrollment window for college students who were on a university-sponsored health plan.
The second option is short-term insurance, also known as "skinny" plans, that have been touted by the Trump administration as an alternative to the federal health marketplace.
The Trump administration approved in October 2018 allowing states to apply for waivers to the ACA in order to offer alternative health-insurance options that include cheaper and limited short-term plans.
Under the Obama administration, short-term plans could last just three months
The Trump administration expanded the coverage period to six months to make the plans more attractive.
Trump administration health and U.S. Treasury officials said the waivers "ensure that people with preexisting conditions are protected" under the ACA.
Frederick Isasi, the executive director of left-leaning advocacy group Families USA, said the nonpartisan Congressional Budget Office found that people with preexisting conditions "would either pay much higher premiums or be left unable to obtain insurance at all" in some short-term plans.
The ACA allows for waivers "so long as the new state waiver plan meets specific criteria, or "guardrails."
Those guardrails help guarantee individuals retain access to coverage that is at least as comprehensive and affordable as without the waiver, covers as many individuals, and is deficit neutral to the federal government.
There also have been concerns that short-term plans wouldn't cover other essential benefits, such as wellness care, or offer prescription drug discounts.
Some unemployed individuals may qualify for Medicaid coverage if their household income had decline to within 138% of the federal poverty criteria: $17,618 a year for an individual and $36,158 a year for a family of four.
According to the Kaiser Family Foundation, about 6 million Americans qualified for Medicaid coverage before the coronavirus-related job cuts and furloughs.
However, the vast majority of those individuals live in the 37 states that have expanded their Medicaid programs.
In North Carolina Republican legislative leaders, foremost N.C. Senate leader Phil Berger of Rockingham, have pointedly declined to expand the state Medicaid program since 2013 even though several studies have shown that between 450,000 and 650,000 North Carolina could benefit.
State unemployment-insurance benefits count as income toward Medicaid eligibility, but the federal stimulus payments do not.
Medicaid coverage is retroactive, but processing applications can take up to 30 days.
"Given that Medicaid eligibility under expansion is determined by income, this number (of potential N.C. enrollees) would likely grow substantially given the significant income and job losses thus far as a result of the outbreak and the future losses to follow," said Suzy Khachaturyan, a policy analyst with left-leaning N.C. Justice Center.
"It is essential that everyone can access health services, including testing and treatment of the coronavirus disease."
For households with children, the North Carolina version of the Children's Health Insurance Program, or CHIP, is an option.
Families already paying for CHIP coverage may qualify for a temporary decreased rate while unemployed.
Getting the word out
Insurers and health-care groups and advocates are attempting to get the word out about enrolling on the federal health exchange or Medicaid.
That's because President Donald Trump chose in late March not to open marketplace enrollment for anyone wanting health-insurance coverage.
Instead, Trump and administration health-care officials are promoting diverting some of the $100 billion dedicated to not-for-profit hospitals within the $2 trillion federal stimulus package.
Their preliminary plan is to use some of those funds to directly pay for COVID-19 patient treatments.
"We are going to get a cash payment to the people and we are working out the mechanics of that with the legislature," Trump said.
"So we are going to try and get them a cash payment because just opening (federal marketplace) up doesn't help as much, so we're going to work it out."
Blue Cross NC, Cigna and UnitedHealthcare are waiving member cost-sharing - including deductibles, co-payments and coinsurance - for treatments related to COVID-19 through June 1.
The member must be diagnosed with the virus to be eligible for the waiving of the cost sharing.
Blue Cross NC members include those covered by employer insurance, the State Health Plan and Medicare. Self-funded employer groups will be given the option to apply these changes to their employees' plans.
"Blue Cross NC is doing all it can to make sure costs are not a barrier to care," said Gerald Petkau, the insurer's interim chief executive.
"This is a public-health emergency that is requiring everyone in the health-care community to do their part, and we'll continue to respond and determine how to best serve our members in the face of COVID-19."
Blue Cross NC is waiving cost sharing for in-network and out-of-network providers. All three insurers will reimburse providers in full at its in-network or Medicare rates.
All three insurers are waiving out-of-pocket costs for COVID-19 testing and increasing access to medications by waiving early medication refill limits.
Trump's plan to use stimulus funding to pay for COVID-19 treatments is too narrowly defined, according to critics.
They claim it won't provide health coverage for someone newly uninsured, or a family member, who has a different health crisis, whether a cancer diagnosis, a broken bone, or treatments for heart disease, diabetes or dental care.
"They're not going to just get COVID-19," U.S. Rep. Donna Shalala, D-Fla., who ran the U.S Department of Heath and Human Services in the Clinton administration, told Politico.
"They'll have other diseases - and they won't have health insurance because they've lost it connected to their job," Shalala said.
A Morning Consult/Politico poll released Wednesday found that 50% of registered voters disapprove of Trump's decision not to reopen the HealthCare.gov portal for a special enrollment period, while 30% approve.
"Everyone in North Carolina should be able to access affordable health-care coverage, and that is especially true in the midst of this global pandemic," said Casey Wilkinson, the executive director of Piedmont Rising, a left-leaning public-health advocacy group.
"While (Republican) Sens. Thom Tillis and Richard Burr have repeatedly voted to put health care out of reach for too many North Carolinians, they can take action now by calling on President Trump to reverse course and open a special open enrollment period.
"There's no reason, other than political games, why North Carolinians without insurance shouldn't be able to gain coverage for themselves and their families immediately," Wilkinson said.