The risk of losing health insurance in the United States is large, and remained so after the Affordable Care Act.

Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID United States, we estimate that while 12.5% of individuals under 65 are uninsured at a point in time, twice as many-one in four-are uninsured at some point over a 2-y period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA. Risk of insurance loss is particularly high for those with health insurance through Medicaid or private exchanges; they have a 20% chance of losing coverage at some point over a 2-y period, compared to 8.5% for those with employer-provided coverage. Those who lose insurance can experience prolonged periods without coverage; about half are still uninsured 6 mo later, and almost one-quarter are uninsured for the subsequent 2 y. These facts suggest that research and policy attention should focus not only on the "headline number" of the share of the population uninsured at a point in time, but also on the stability and certainty (or lack thereof) of being insured.

The Impact of Increased Access to Telemedicine

We estimate the impact of increased access to telemedicine that followed widespread adoption during the March-April 2020 lockdown period in Israel (due to COVID-19). We focus on the post-lockdown period, which in Israel was characterized by a temporary return to normalcy. Prior to the lockdown, telemedicine accounted for about 5% of all primary care visits. It peaked at around 40% during the lockdown, and remained high, at around 20%, during the post-lockdown period. Using a difference-in-differences framework, we compare primary care episodes before and after the lockdown between patients with high and low access to telemedicine, with access defined based on their main primary care physician’s propensity to adopt telemedicine during the lockdown. Increased access to telemedicine results in a 3.5% increase in primary care visits, but a 5% lower per-episode cost, so overall resource utilization is slightly lower. We find that remote visits involve slightly fewer prescriptions and more follow-ups, mainly with the same physician, which is consistent with a prolonged diagnostic path in the absence of physical examination. However, analyzing specific conditions, we find no evidence of missed diagnoses or adverse outcomes. Taken together, our findings suggest that the increased convenience of telemedicine does not compromise care quality or raise costs.