Helmsley: Patterns of Delayed Healthcare.

Patterns of Delayed Healthcare Among New Yorkers with High Healthcare Need Over the Course of the Pandemic

Anastasia Koutavas, Mustafa Hussein, Lily Bushman-Copp, and Christopher Wimer

July 2026

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 1

INTRODUCTION

At the onset of the COVID-19 pandemic, Columbia University, with support from Robin Hood and The Leona M. and Harry B. Helmsley Charitable Trust, began collecting data on healthcare access and utilization across New York City via the Poverty Tracker (see text box). The objective was to better understand the healthcare needs of New Yorkers and the difficulties they faced in meeting those needs. As the pandemic strained healthcare systems nationwide, Poverty Track- er data offered a unique opportunity to understand changes in access and utilization at the lo- cal level. The data revealed two patterns: first, New Yorkers experiencing poverty or material hardship had a greater need for healthcare due to chronic or work-limiting health conditions. Second, those who had a greater need for care were more likely to delay (and in many cases, entirely forgo) such care, and this was especially true of New Yorkers facing poverty or material hardship. 1 As the pandemic has waned in intensity over time, questions about its lingering effects on access to health- care continue to be raised, especially among vulnerable populations. Since 2020, the Poverty Tracker has collected data on healthcare use and access that allow us to explore how disparities in healthcare outcomes have evolved over the course of the pandemic. This pair of briefs follow up on the healthcare experiences of New Yorkers with high healthcare needs since the onset of the COVID-19 pandemic. We explore changes in core measures of healthcare access during the pandemic and how these measures have varied among New Yorkers with different economic backgrounds. In this brief, we focus specifically on changes in delayed and forgone care among New Yorkers with high healthcare needs, their reasons for doing so, and the role affordability plays in shaping their access to care. Instances of delayed care are just one example of the disruptions the pandemic imposed on healthcare ac- cess and utilization. 2 Understanding changes in the experience and drivers of delaying or forgoing care over the course of the pandemic, is critical to improving healthcare access for New Yorkers of various economic backgrounds, especially those with high healthcare needs.

1 Maury et al., “Health and healthcare in New York City: second report.” 2 Czeisler et al., “Delay or avoidance of medical care because of COVID-19–related concerns — United States, June 2020.”

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 2

KEY FINDINGS g Economically disadvantaged New Yorkers were more likely to delay or forgo physical health- care than more-advantaged New Yorkers, and this gap grew as the pandemic began to subside. In 2022, economically disadvantaged New Yorkers were 31 percentage points more likely to delay or forgo physical healthcare relative to more-advantaged New Yorkers, up from an eight-percentage-point gap in 2021. g Economically disadvantaged New Yorkers were also more likely than more advantaged New Yorkers to delay or forgo mental healthcare, and this gap persisted throughout the pandemic. In 2022, 53% of economically disadvantaged New Yorkers delayed or went without mental healthcare, compared to 41% of more-advantaged New Yorkers. g Forgoing mental healthcare was much more common than forgoing physical healthcare, regardless of economic disadvantage. In 2022, for example, roughly 42% of high-need, eco- nomically disadvantaged New Yorkers went without the mental healthcare they needed, while a smaller 17% forwent the physical healthcare they needed. g In 2021, the pandemic was a primary reason that high-need New Yorkers delayed or forwent healthcare, regardless of economic disadvantage. But as the pandemic began to recede in 2022, high-need New Yorkers—especially those facing economic disadvantage—increas- ingly cited the affordability and availability of healthcare as barriers to care. g Health insurance can make healthcare more accessible, but insurance coverage does not guarantee access. Economically disadvantaged, high-need New Yorkers saw a drop in health insurance coverage throughout the pandemic (88% had coverage in 2022, compared to 96% in 2021). Almost all more-advantaged high-need New Yorkers had health insurance cover- age throughout the pandemic (98% in 2021 and 99% in 2022). In our study period (2021 to 2022):

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 3

About the Poverty Tracke r Launched in 2012, the Poverty Tracker surveys a representative sample of New Yorkers sever- al times throughout the year, providing critical information on the dynamics of poverty and other forms of disadvantage in the city. Unlike other surveys, the Poverty Tracker explores how New York- ers experience poverty and material hardship over time, rather than in a single day, month, or year. In addition, the Poverty Tracker focuses on more than income poverty; annually, the study collects data on other core measures of disadvantage, such as material hardships and health problems. We use these alternative measures to understand how certain types of disadvantage, or multiple, overlapping sources of disadvantage, make it harder for New Yorkers to get by. The Poverty Tracker also collects data on other aspects related to New Yorkers’ well-being, from asset and debt accu- mulation, to social service program utilization, to spending and consumption patterns, in order to form a better understanding of how New Yorkers are faring within the city. Our approach In this report, we follow changes in the healthcare experiences of New Yorkers with high healthcare need (hereafter, “high-need”). We define high need as having multiple chronic health conditions, a work-limiting health condition, or serious psychological distress (see text box). We distinguish between high-need New Yorkers with and without economic disadvantage over two time periods: 2021 and 2022. 3 Economic disad- vantage is defined as being in poverty (as defined by the Supplemental Poverty Measure, or SPM) or expe- riencing material hardship (reporting difficulty meeting basic needs). 4 Our sample contains 705 high-need New Yorkers, 371 of whom are economically disadvantaged. 5 High healthcare need (high need) Multiple chronic health conditions Two or more of the following self-reported chronic health conditions: asthma, diabetes, hypertension, cancer, heart disease

Work-limiting health condition

A health problem or disability that prevents one from working or limits the kind or amount of work one can do A value of 13 or greater on the Kessler Psychological Distress Scale (K6), which indicates serious psychological distress.

Serious psychological distress

3 This analysis utilizes the Poverty Tracker’s longitudinal structure. The first period covers surveys conducted between October 2020 and June 2021. The second period covers surveys conducted between April 2022 and November 2022. 4 For this report, we define poverty using the Supplemental Poverty Measure, prior to the subtraction of medical out-of-pocket expenses from resourc- es. For a more detailed definition of poverty and material hardship, see “The state of poverty and disadvantage in New York City: volume 7,” Poverty Tracker Research Group. We exclude medical out-of-pocket expenses so as to not conflate economic need with high healthcare needs. 5 For this analysis, we statistically control for basic demographic indicators including race, gender, age, and education level.

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 4

Core dimensions of healthcare access

In the health services literature, access to healthcare has five core dimensions, outlined below. 6

In this brief, we explore how instances of delayed and forgone care over the course of the pandemic are related to the availability and affordability dimensions of healthcare access, such as not being able to find an available physician or not being able to afford necessary services. Our next brief explores the remaining dimensions of access. Understanding and addressing such barriers can help improve health outcomes by eliminating reasons that patients might delay or forgo care, especially among high-need New Yorkers. Changes in healthcare needs among high-need New Yorkers During the pandemic, high-need New Yorkers needed physical healthcare. More than half of economical- ly disadvantaged high-need New Yorkers needed care (56% in 2021 and 52% in 2022). More advantaged high-need New Yorkers reported roughly similar levels of physical healthcare needs: 50% in 2021 and 59% in 2022 (Figure 1). The need for mental healthcare among high-need New Yorkers, however, varied substantially by one’s eco- nomic position. In both years explored, about half of economically disadvantaged New Yorkers reported needing mental healthcare, compared to only about one-third of their more-advantaged counterparts (Fig- ure 1). AVAILABILITY : the supply of appropriate care options versus patients’ needs AFFORDABILITY: the cost of services versus patients’ ability to pay or insurance coverage ACCESSIBILITY: the geographic location of healthcare services versus patients’ location and ability to reach them (e.g., transportation) ACCOMMODATION: the organization of services versus patients’ circumstances (e.g., after-hours and weekend appointments) ACCEPTABILITY: the cultural competence in service delivery versus patients’ preferences and beliefs (e.g., feeling welcome or respected by your provider)

6 Penchansky and Thomas, “The concept of access: definition and relationship to consumer satisfaction.”

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 5

Need for healthcare over time among high-need New Yorkers Figure 1

2021

2022

70% 80% 90% 100%

59%

20% 30% 40% 50% 60% 56%

52%

51% 51%

50%

34% 34%

10% 0%

Economic disadvantage

No economic disadvantage

Economic disadvantage

No economic disadvantage

Needed physical healthcare

Needed mental healthcare

Changes in healthcare receipt among high-need New Yorkers The degree to which New Yorkers pursued healthcare changed over the course of the pandemic. While some high-need New Yorkers increasingly pursued the healthcare services they needed, others found themselves delaying—and in some cases forgoing—such care. Rates of receiving, delaying, and forgoing care varied by economic disadvantage (Figure 2).

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 6

Figure 2. Physical healthcare receipt among high-need New Yorkers who reported needing care

Physical healthcare receipt among high-need New Yorkers who reported needing care Figure 2

Delayed Received

Forgone

43%

47%

35%

16%

Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: Results are among high-need New Yorkers who reported needing physical healthcare, as shown in Figure 1. Due to rounding, some figures may not total to 100%.

High-need New Yorkers facing economic disadvantage were slightly more likely to delay or forgo physical healthcare in 2022 (47%) than in 2021 (43%). Moreover, in 2022, they were almost three times more likely to delay or forgo physical healthcare than their more advantaged counterparts (47% versus 16%, respec- tively). Forgoing physical healthcare entirely was also more common among economically disadvantaged New Yorkers in 2022—17% went without care in 2022 versus 4% of more-advantaged New Yorkers—despite some decline in forgone care among both groups over the pandemic. In terms of care received, more-advantaged New Yorkers experienced a substantial increase in the receipt of needed physical healthcare from 2021 (66%) to 2022 (84%) (Figure 2). On the other hand, between 2021 and 2022, economically disadvantaged New Yorkers became less likely to receive the care they needed, from 58% in 2021 to 52% in 2022. All told, economically disadvantaged high-need New Yorkers were 31 per- centage points more likely to delay or forgo physical healthcare than their more-advantaged counterparts in 2022, up from an eight percentage point gap in 2021. This change suggests that economically disadvan- taged New Yorkers struggling with their health continued to experience persistent barriers to care even as the pandemic started to wane, while barriers to care likely declined for their more-advantaged counterparts. Turning to mental health, economically disadvantaged New Yorkers were roughly 1.5 times more likely to need mental healthcare services, such as therapy or counseling, than more-advantaged New Yorkers during the pandemic (Figure 1). Despite greater need, economically disadvantaged New Yorkers were less

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 7

Friegpuorert3e.dMnenetdailnhgecaaltrhecare receipt among high-need New Yorkers who

Mental healthcare receipt among high-need New Yorkers who reported needing care Figure 3

Delayed

Received

Forgone

63%

2021

52%

11%

37%

53%

2022

42%

11%

47%

46%

2021

54%

44%

41%

2022

40%

60%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

likely to receive such services (Figure 3). While both groups experienced an increase in the receipt of mental healthcare over the course of the pandemic, economically disadvantaged New Yorkers were still more likely to delay or forgo mental healthcare in 2022 (53%) than the more-advantaged (41%). Notably, rates of forgone mental healthcare are much higher than rates of forgone physical healthcare, re- gardless of economic status. In 2022, roughly two in five (42%) economically disadvantaged New Yorkers who needed mental healthcare went without it (Figure 3), while less than one in five (17%) went without physical healthcare (Figure 2). Among the more-advantaged, about the same (40%) who expressed need- ing mental healthcare never received that care—while only 4% of those who expressed needing physical healthcare had to forego it. Mental healthcare services are often less frequently pursued than physical healthcare due to a variety of barriers, including high costs, lack of insurance coverage, and the stigma associated with having and seeking care for mental illness. 7 This pattern echoes in our data: while receipt of mental healthcare services grew modestly over the course of the pandemic, mental healthcare remained generally less accessible than physical healthcare services for many high-need New Yorkers. Overall, high-need New Yorkers, especially those facing economic disadvantage, continued to experience alarmingly high levels of delaying or going without care throughout the pandemic. We now turn to the question of which factors may have been responsible for these patterns. 43% 47% 35% 16%

7 Demyttenaere et al., “Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys”; Andrade et al., “Barriers to mental health treatment: Results from the WHO World Mental Health surveys”; KFF, “Mental health in New York (fact sheet)”; Sareen et al., “Perceived barriers to mental health service utilization in the United States, Ontario, and the Netherlands”; Tomczyk et al., “A prospective study on structural and attitudinal barriers to professional help-seeking for currently untreated mental health problems in the community.”

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 8

Reasons for delaying or forgoing healthcare among high-need New Yorkers Delaying or forgoing necessary healthcare can lead to worsening symptoms and exacerbate the underlying illness, thus potentially increasing the future need for care. 8 The decision to delay or forgo care, however, can be driven by a variety of factors. Angela, a New Yorker we interviewed at length about her experiences with the healthcare system, describes the complex ways these factors play out in people’s real lives. Pursuing healthcare under economic duress: Angela’s story Angela has been in the shelter system since losing her apartment shortly before the pandemic be- gan. She contends with chronic health conditions, including arthritis and hypertension, and is a single parent of three children, all of whom have developmental delays. Her story illustrates how balancing a family’s high healthcare needs with the pressures of economic disadvantage and unstable living conditions can lead one to delay or even forgo needed physical and mental healthcare. Navigating doctor’s appointments for her children in the city hospitals where they receive care became increasingly challenging for Angela since the restrictions were put in place at the height of COVID: “It took me three months to get them [annual] physicals because you can’t bring all the kids together anymore.” Meanwhile, getting her own appointments with any provider besides a general practitioner became more difficult: “This [rheumatology] appointment only comes around once a month, and can only be done at one time in the morning. They don’t even have later appointments, nothing past noon. Any kind of specialty thing, which was hard before COVID, is impossible now.” Given this restricted avail- ability, Angela sometimes lost crucial income in favor of a doctor’s appointment: “ Your next appoint- ment will be next month, so you can’t miss that appointment. I actually missed a job on the fourth because I [had] to go [for an] MRI… I wanted that money, but my health is more important. ” Angela knew the stakes of missing an appointment that could not be easily rebooked: “ For the ophthalmolo- gy appointment, I waited a whole year. They gave me the appointment two months afterwards—two months after I requested it, but it was like for next year. I was like, ‘What? Does that really say 2023? ’” When insurance does not cover certain care, many postpone it indefinitely; for Angela, this was the case with much-needed mental healthcare. Given the stressors of being a single parent of high-need children, managing remote schooling during the pandemic and continually searching for an afford- able apartment, Angela feels she could benefit from a counselor’s support. However, she has had difficulty finding mental health services that are the right fit and covered by insurance. She sought care through a CNYC website that claimed to offer free counseling, but, she says: “ I couldn’t get past their automated thing, and the automated thing was like, ‘Do you wanna kill yourself? Do you wanna kill yourself? Do you wanna kill yourself?’ Like, ‘No!’ It’s like it became painfully aware to me that it was for people who were in crisis. It’s like, ‘I’m not in crisis, but I don’t wanna get there.’” Angela knows that seeking mental healthcare through her primary care doctor can “take forever,” as it requires securing a referral and then waiting for a mental health provider to have availability, let alone knowing if that person will be the right fit. And a good fit in a therapist was key for Angela, who notes, “A therapist actually has to have a relationship with you.” She expects that she will need to seek this care outside of what is covered by her insurance: “I just get the feeling that [therapy is] something I’m gonna have to pay for… but I just can’t afford it right now.” At the follow up interview a year and a half later, she still has not received this care.

8 Weissman et al., “Delayed access to health care: Risk factors, reasons, and consequences.”

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 9

The Poverty Tracker surveys asked respondents what led them to delay or forgo care, with some possible reasons including: (1) the COVID-19 pandemic; (2) the cost of care; (3) not having insurance; (4) not having a regular doctor; and (5) not knowing where to receive care (Figure 4). 9 Reasons for delaying or forgoing healthcare among high-need New Yorkers Figure 4 Figure 4. Reasons for delaying or forgoing care among high-need New Yorkers

2021

2022

Among high-need New Yorkers facing economic disadvantage...

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

54%

49%

42%

24% 23%

20%

19%

17%

13%

12%

COVID-19 pandemic Cost of seeing a doctor was too high

Did not have insurance

Did not have a regular doctor

Did not know where to go for care

2021

2022

Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Among high-need New Yorkers not facing economic disadvantage...

20% 30% 40% 50% 60% 70% 80% 90% 100%

69%

36%

24%

20%

16%

13%

10% 0%

0% 1%

Did not have insurance

COVID-19 pandemic Cost of seeing a doctor was too high

Did not know where to go for care

Did not have a regular doctor

Source: Poverty Tracker longitudinal survey data; cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: Results are among high-need New Yorkers who have delayed or forgone physical or mental healthcare. Reasons for delaying or forgoing care are not mutually exclusive. Note: Results are among high-need New Yorkers who have delayed or forgone physical or mental healthcare. Reasons for delaying or forgoing care are not mutually exclusive.

9 See Appendix A, Table A1 for additional results on why high-need New Yorkers reported delaying or forgoing healthcare.

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 10

The COVID-19 pandemic was the most common reason that high-need New Yorkers delayed or forwent care in 2021, with more than half of economically disadvantaged New Yorkers (54%) and more than two- thirds of more-advantaged New Yorkers (69%) citing it. Notably, the pandemic became less of an obstacle over time: in 2022, only 19% of economically disadvantaged New Yorkers and 36% of more-advantaged New Yorkers who delayed or forwent care did so due to the pandemic. For economically disadvantaged New Yorkers, affordability of care was a significant obstacle to receiving care in both 2021 and 2022. High cost of care became the most common reason that economically disad- vantaged New Yorkers delayed or forwent care in 2022 (42%), despite a decrease relative to 2021 (49%), and they were three times more likely than more-advantaged New Yorkers (13%) to cite this reason. Lack of insurance coverage was also a notable barrier to healthcare access for economically disadvantaged New Yorkers: one in five (20%) delayed or went without healthcare in 2022 because of a lack of insurance, a sev- en-percentage-point increase from earlier in the pandemic (13%). By contrast, a lack of insurance hindered just 1% of more-advantaged New Yorkers from receiving care in 2022. 10 In 2022, economically disadvantaged New Yorkers also struggled with the availability of healthcare. They increasingly delayed or forwent care because they did not have a regular doctor (from 12% in 2021 to 17% in 2022), while more-advantaged New Yorkers experienced a decrease in this issue, from 16% to 4%. Further, about a quarter (24%) of economically disadvantaged New Yorkers who delayed or went without healthcare in 2021 did so because they did not know where to go to receive care, a reason that persisted in 2022 (23%). In comparison, 20% of more-advantaged New Yorkers delayed or forwent care because they did not know where to go in 2022, down from 24% in 2021. While the pandemic itself played a substantial role in keeping high-need New Yorkers from receiving the care that they needed, other factors continued to make it difficult for high-need New Yorkers to receive healthcare. Issues of affordability, as well as the availability of care, limited healthcare use among high-need New Yorkers, especially among those facing economic disadvantage. Below, we continue to explore how affordability continues to be a barrier to healthcare access among high-need New Yorkers. Healthcare affordability and economic barriers to care Affordability is a core determinant of the ability to receive healthcare. As seen above, the cost of receiving healthcare can prevent those with high need from getting the care they need, especially those already fac- ing economic disadvantage. We now zoom in on economic barriers to healthcare receipt among high-need New Yorkers over the course of the pandemic, focusing on prescription drug access and health insurance coverage. Earlier, we found that one reason high-need New Yorkers delayed healthcare was because the cost to see a physician was too high. However, patients often bear other costs too: prescriptions and needed medical de- vices may be expensive, even among patients with health insurance. During the pandemic, high-need New Yorkers facing economic disadvantage were more likely to skip, take less of, or delay filling a prescription than their more-advantaged counterparts (Figure 5). While skipping or delaying a prescription became less common among more-advantaged New Yorkers as the pandemic started to wane (6% in 2022, compared to

10 Tipirneni et al., “Association between health insurance literacy and avoidance of health care services owing to cost.”

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 11

11% in 2021), economically disadvantaged New Yorkers continued to skip or delay filling their prescriptions at similar rates (16% in 2021 and 17% in 2022). This shift led to a widening disparity in prescription utilization as the pandemic started receding, and suggests that, for high-need New Yorkers facing economic disad- vantage, there is a continued need for supports that enable these New Yorkers to regularly access, fill, and take their prescription medications. Share of high-need New Yorkers who skipped, took less, or delayed filling a prescription due to cost Figure 5 Figure 5. Share of high-need New Yorkers who skipped, took less, or delayed filling a prescription due to cost

2021

2022

25%

20%

17%

16%

15%

11%

10%

Economic disadvantage

No economic disadvantage

Although health insurance can address many barriers to healthcare by reducing the out-of-pocket cost of prescriptions, care visits, and procedures, health insurance coverage is not a guarantee of access. Some health services may not be covered by insurance plans, and difficulty navigating coverage and find- ing care options can contribute to instances of delayed and forgone care. 11 Figure 6 shows differences in health insurance coverage among high-need New Yorkers over the course of the pandemic. Economical- ly disadvantaged, high-need New Yorkers appear to have experienced an eight percentage point drop in self-reported insurance coverage over the course of the pandemic (96% in 2021 versus 88% in 2022). Almost all more-advantaged, high-need New Yorkers had insurance coverage throughout the pandemic (98% in 2021 and 99% in 2022). The widening gap in health insurance coverage suggests that issues of affordability can especially hinder those experiencing poverty or hardship from pursuing—and eventually receiving—necessary healthcare.

11 While our results find a potential decline in health insurance coverage over the pandemic, some research suggests that there is a discrepancy between self-reported health insurance coverage and administrative counts of coverage. For more information, see Ding, Sommers, and Glied, “Unwinding and the Medicaid undercount: millions enrolled in Medicaid during the pandemic thought they were uninsured.”; McIntyre, Smith and Sommers, “Survey-re- ported coverage in 2019-2022 and implications for unwinding Medicaid continuous eligibility.”

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 12

Health insurance coverage and type among high-need New Yorkers Figure 6 Figure 6. Changes in insurance status and type among high-need New Yorkers

g Among the insured:

2021 2022

Public insurance Private insurance

98% 99%

20% 30% 40% 50% 60% 70% 80% 90% 100% 96% 20% 30% 40% 50% 60% 70% 80% 90% 100% 96% 2021 2022

100%

88%

98% 99%

88%

80%

67%

61%

60%

84%

85%

40%

39%

20%

33%

10% 0%

16%

15%

Economic disadvantage No economic disadvantage Economic disadvantage No economic disadvantage

2021

2022

2021

2022

Source: Poverty Tracker longitudinal survey data; cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Due to rounding procedures, some totals might not sum to 100. Note: The sample size for results on type of insurance is smaller than that of general insurance coverage, as not all Poverty Tracker respondents in this analysis were asked about their type of insurance. Private insurance defined as health insurance coverage from one’s own employer,

Economic disadvantage

No economic disadvantage

Most insured, high-need New Yorkers are covered by public health insurance, although economically dis- advantaged New Yorkers are more likely than the more-advantaged to be covered by public health insur- ance (85% vs 67% in 2022) (Figure 6). High levels of public insurance coverage for both groups in 2021 and 2022 is consistent with rising Medicaid enrollment and stabilization during that time, which helped offset declines in private coverage due to employment losses during the pandemic recession. 12 Nonetheless, giv- en their disproportionately high reliance on public health insurance, the economically disadvantaged are at further risk of losing coverage and access as the protections to Medicaid expired together with the pan- demic’s public health emergency in 2023. 13 Health insurance coverage is essential for receiving affordable and adequate care; however, access to health insurance is tied to income limits, employment status, and other eligibility requirements. In the box below, Kim, a high-need New Yorker, explains her experiences with changes to her health insurance, the consequences of losing coverage, and the precarity of securing affordable healthcare for her chronic conditions. someone else’s employer, COBRA, or another plan bought or owned. Public insurance defined as being covered by Medicaid, Medicare, or military insurance (including TRICARE, CHAMPUS, and Veteran’s Affairs), or some other source. Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Due to rounding, some totals might not sum to 100. Note: The sample size for results on type of insurance is smaller than that of general insurance coverage, as not all Poverty Tracker respondents in this analysis were asked about their type of insurance. Private insurance defined as health insurance coverage from one’s own employer, someone else’s employer, COBRA, or another plan individually purchased. Public insurance defined as being covered by Medicaid, Medicare, or military insurance (including TRICARE, CHAMPUS, and Veteran’s Affairs), or some other source.

12 Lukens, Sullivan and Erzouki, “COVID relief provisions stabilized health coverage, improved access and affordability.”; Jacobs and Moriya, “Changes in health coverage during the COVID-19 pandemic.”; Benitez, “Comparison of unemployment-related health insurance coverage changes in Medicaid expansion vs non-expansion states during the COVID-19 pandemic.” 13 McIntyre et al., “Coverage and access changes during Medicaid unwinding.”

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 13

Care, cost and coverage: Kim’s experiences with health insurance volatility Kim, 36, moved to New York City as a teenager for “a fresh start.” During the pandemic, she lost her retail job and now supplements an irregular income from freelance graphic design by picking up oc- casional housekeeping work “to make sure that ends meet completely.” Her $1,300 rent is subsidized by the HIV/AIDS Services Administration (HASA), and covering it “gets tough sometimes, [but] it’s a lot easier than being homeless again,” as she was for about a year prior to securing her apartment. Born with HIV and managing a related chronic lung condition as well as mental health challenges, Kim chose not to enter the workforce full time because of difficulties not just with her health, but also with health insurance. She has Medicaid and a supplemental insurance, which cover most of her frequent doctors’ visits and daily medications, as well as the occasional health crises she experiences. Public insurance has been less precarious for Kim than the employer-based insurance she previously had: “Suddenly, [my employer] dropped my health insurance. I could only go and see my provider three times a year or two times a year without any emergency visits included. They, suddenly, didn’t cover my medications either, which was a huge deal because the medication cost about—outta pocket, it would be about $1,000 a month. I couldn’t afford that at all, and I still can’t. Suddenly, I didn’t have health insurance for six months. I couldn’t afford my medication for six months. With it be- ing a chronic illness, I, suddenly, got really sick really quickly. That’s why I’m really skittish about even trying that again, going through an employer [for insurance].” Kim left that job in order to get back on Medicaid, and her health did not stabilize for another year. High-need, economically disadvantaged New Yorkers have a stable and reliable option in public in- surance, as enrollment rates attest to, though this may come at the expense of pursuing a higher income. And although it is consistent, public insurance—like private coverage—guarantee neither timeliness nor affordability of care:

“It is difficult in that, when the doctor prescribes a certain treatment or medi- cation, [you] can’t get the medication right away, or you can’t get the treatment right away, even though you might need it right away. You have to go through the whole application system. Sometimes, you get denied, and then you have to appeal .... basically havin’ to plead with strangers that you are actually sick, even from a hospital bed.”

Kim delayed a needed jaw bone graft for almost three years for this reason, and when she eventually had the procedure, Medicaid only covered the appointments, while Kim was left with a $15,000 bill. She paid for this using a “Care Credit” card, which is interest-free as long as she pays the $1,000 an- nual minimum. She has missed payments in the past and used “the whole trick of maxing out other cards to pay [it]” and avoid accruing interest. Specialists within the hospital network can have long waitlists, but if the cost of care elsewhere is high, waiting months for an appointment is the only op-

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 14

tion; Kim chose to delay a gastroenterology appointment that would cost $75 per visit and $50 for bloodwork at another provider. Having public insurance can make finding providers more challeng- ing, especially when health needs are complex:

“[I’m] very limited by which dentists take which health insurance and which ones are good at—also, because of the chronic illness, there’s always that is- sue of, I guess, things are different. When you ask a provider, they take your insurance, but they’re not really comfortable dealing with someone who has a chronic illness or this particular chronic illness. It’s been really difficult.”

Over time, Kim has found it more important to find providers who are a good fit: “Before, I would just go with anyone as long as they take my insurance and they’re a provider. Now, I’m tryin’ to find someone who I’m comfortable with and who I can actually talk to and ask questions and get proper healthcare and not just, ‘Let’s fix this problem as quickly as possible.’” Kim’s experiences highlight that, although health insurance is necessary to receive care, insur- ance coverage is not a guarantee of access to needed services. While public insurance offers sta- ble coverage, the challenges with finding providers who take it undermine its effectiveness. High cost-sharing and rising premiums, paperwork burden, restrictive networks, and instability also un- dermine the benefits of having private insurance, including through an employer, leaving high-need New Yorkers with steep healthcare bills to pay. These challenges are consistent with our observa- tions that insurance- and cost-related barriers to care continue at high rates among high-need New Yorkers facing economic disadvantage, even though a majority of them have health insurance.

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 15

CONCLUSION Over the course of the pandemic, high-need New Yorkers’ needs for healthcare changed, as did their ability to receive it. Despite their similar or even greater need throughout the pandemic, economically disadvan- taged New Yorkers were much less likely to receive the healthcare that they needed than their more-ad- vantaged counterparts. Specifically, economically disadvantaged New Yorkers were almost three times as likely to delay or forgo physical healthcare than more-advantaged New Yorkers in 2022—a wider gap in delayed or forgone care than in 2021. They were also more likely to delay or forgo mental healthcare than the more-advantaged in both 2021 and 2022. Although both groups saw modest growth in receipt of mental healthcare services over the course of the pandemic, mental healthcare remained generally less accessible than physical healthcare services for many high-need New Yorkers. Reasons for delaying care varied. The pandemic was a primary reason that high-need New Yorkers delayed healthcare and it became less of a barrier over time. However, the persisting economic disparities in delayed or forgone care point to the severity of other barriers to accessing healthcare that go beyond the temporary shock of the pandemic. Namely, affordability concerns—such as the high cost of care—contributed to high levels of delayed and forgone care, especially among the economically disadvantaged. Insurance coverage also appears to have declined among economically disadvantaged New Yorkers as the pandemic started receding, further exacerbating inequalities in the City among those struggling with healthcare needs. New York City, in many ways, remains a city divided between those with economic security and those struggling to get by. As the pandemic has waned, our results suggest that structural inequalities in access to and utili- zation of healthcare have unfortunately begun to re-emerge.

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 16

APPENDIX A. Additional results

Table A1. Reasons for delaying or forgoing healthcare among high-need New Yorkers

Delayed or forwent healthcare because…

No economic disadvantage

Economic disadvantage

2021 54%

2022 19% 42% 23% 19% 12% 20%

2021

2022

COVID-19 pandemic

69% 36%

Cost to see healthcare professional was too high 49%

13%

Did not know where to go Have not gotten around to it

24% 17% 16% 13% 12% 12%

24% 20%

19%

29%

Lack of transportation Did not have insurance

7% 1%

<1% 16%

Did not have a regular doctor

17% 10% 11% 18%

14%

Concerns about how you would be treated Did not know how to make an appointment

26% 28%

12% 15%

4% 9%

Other reason

24%

Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: Results among high-need New Yorkers who delayed or forwent either physical or mental healthcare. Reasons for delaying care are not mutually exclusive.

PATTERNS OF DELAYED HEALTHCARE AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 17

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