Using the attached template, critically appraise the following article (attached in the Articles section). 

Rubric for Article Critique Reports

Week

4

– Assignments 4a and 4b

3

3

3

3

3

3

3

5

3

5

5

5

5

5

3

3

3

2

5

3

5

3

5

Assignment 4 (indicate 4a or 4b)

Part

Question

Answer

Points

Title

1.Title of the article, journal name, your name

3

Purpose/Research problem

2 a. What is the purpose of the study? Is it clearly identified? Is the research problem important?

5

2b. Identify the dependent variable(s)

2c. Identify the independent variable(s)

Literature review

3a. Are the cited sources relevant to the study?

3b. Does the literature review offer a balanced critical analysis of the literature?

3c. Are the cited studies recent?

Theoretical framework*

4a. Has a conceptual or theoretical framework been identified?

4b. If yes, is the framework adequately described?

Design and procedures

5a. Identify the study design used in this study? Make sure that you select the exact type of design used, i.e., one of the three discussed this week.

5b. Is the study design appropriate to answer the research question?

5c. What type of sampling design was used?

5d. Was the sample size justified on the basis of a power analysis or other rationale?

5e. Are the inclusion and exclusion criteria clearly identified? What are they?

5f. What measurement tools were used for the dependent variable(s)?

5g. What measurement tools were used for the independent variable(s)?

5h. Were validity and reliability issues discussed?

4

Ethical considerations

6a. Were the participants fully informed about the nature of the research?

6b. Were the participants protected from harm?

2

6c. Was ethical permission granted for the study?

Data analysis

7a. What type of data and statistical analysis was undertaken?

7b. Was the statistical analysis appropriate to address the research question?

Results

8. What are the results of the study? Did the results answer the research question(s)?

Discussion

9a. Were the findings linked back to the literature review?

9b. Did the authors identify study limitations? What were they?

9c. Do you think the limitations are serious enough to impact the internal and external validity** of the study?

Overall assessment

10. What is your overall assessment of the study?

Total

100

Source: Coughlan M, Cronin P, Ryan F. Step-by-step guide to critiquing research. Part 1: quantitative research. Br J Nurs. 2007;16(11):658-63.

* A conceptual or theoretical framework/model is a representation of a concept and the relationships between this concept and other variables that might impact it or be affected by it. It provides structure to a study and a rationale for the different relationships between the variables. Not every study has to have a conceptual or theoretical framework clearly outlined. The better research questions are usually the ones informed by theory and a corresponding framework. For an example, check the following article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934012/

** The validity of a study, in contrast to the validity of measurements, is the degree to which study results are accurate and well-founded, when account is taken of study methods, representativeness of study sample, and nature of the population from which it is drawn.

· Internal validity (results are attributed to hypothesized effect and not sample differences)

· External validity (generalizability)

Original Investigation | Health Policy

Reports of Forgone Medical Care Among US Adults
During the Initial Phase of the COVID-19 Pandemic
Kelly E. Anderson, MPP; Emma E. McGinty, PhD, MS; Rachel Presskreischer, MS; Colleen L. Barry, PhD, MPP

Abstract

IMPORTANCE The coronavirus disease 2019 (COVID-19) pandemic has caused major disruptions in
the US health care system.

OBJECTIVE To estimate frequency of and reasons for reported forgone medical care from March to
mid-July 2020 and examine characteristics of US adults who reported forgoing care.

DESIGN, SETTING, AND PARTICIPANTS This survey study used data from the second wave of the
Johns Hopkins COVID-19 Civic Life and Public Health Survey, fielded from July 7 to July 22, 2020.
Respondents included a national sample of 1337 individuals aged 18 years or older in the US who were
part of National Opinion Research Center’s AmeriSpeak Panel.

EXPOSURES The initial period of the COVID-19 pandemic in the US, defined as from March to mid-
July 2020.

MAIN OUTCOMES AND MEASURES The primary outcomes were missed doses of prescription
medications; forgone preventive and other general medical care, mental health care, and elective
surgeries; forgone care for new severe health issues; and reasons for forgoing care.

RESULTS Of 1468 individuals who completed wave 1 of the Johns Hopkins COVID-19 Civic Life and
Public Health Survey (70.4% completion rate), 1337 completed wave 2 (91.1% completion rate). The
sample of respondents included 691 (52%) women, 840 non-Hispanic White individuals (63%), 16

0

non-Hispanic Black individuals (12%), and 223 Hispanic individuals (17%). The mean (SE) age of
respondents was 48 (0.78) years. A total of 544 respondents (41%) forwent medical care from March
through mid-July 2020. Among 1055 individuals (79%) who reported needing care, 544 (52%)
reported forgoing care for any reason, 307 (29%) forwent care owing to fear of severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, and 75 (7%) forwent care owing to
financial concerns associated with the COVID-19 pandemic. Respondents who were unemployed,
compared with those who were employed, forwent care more often (121 of 186 respondents [65%]
vs 251 of 503 respondents [50%]; P = .01) and were more likely to attribute forgone care to fear of
SARS-CoV-2 transmission (78 of 186 respondents [42%] vs 120 of 503 respondents [24%]; P = .002)
and financial concerns (36 of 186 respondents [20%] vs 28 of 503 respondents [6%]; P = .001).
Respondents lacking health insurance were more likely to attribute forgone care to financial concerns
than respondents with Medicare or commercial coverage (19 of 88 respondents [22%] vs 32 of 768
respondents [4%]; P < .001). Frequency of and reasons for forgone care differed in some instances by race/ethnicity, socioeconomic status, age, and health status.

(continued)

Key Points
Question What are the frequency of
and reasons for reported forgone

medical care from March to mid-July

2020, the initial phase of the

coronavirus disease 2019 (COVID-19)

pandemic in the US?

Findings In this national survey of 1337
participants, 41% of respondents

reported forgoing medical care from

March through mid-July 2020. Among

adults who reported needing care

during this period, more than half

reported forgoing care for any reason,

more than one-quarter reported

forgoing care owing to fear of severe

acute respiratory syndrome coronavirus

2 transmission, and 7% reported

forgoing care owing to financial

concerns.

Meaning This survey study found that
there was a high frequency of forgone

care from March to mid-July 2020, with

respondents commonly attributing the

causes of forgone care to repercussions

of the COVID-19 pandemic.

+ Supplemental content
Author affiliations and article information are
listed at the end of this article.

Open Access. This is an open access article distributed under the terms of the CC-BY License.

JAMA Network Open. 2021;4(1):e2034882. doi:10.1001/jamanetworkopen.2020.34882 (Reprinted) January 21, 2021 1/11

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Abstract (continued)

CONCLUSIONS AND RELEVANCE This survey study found a high frequency of forgone care among
US adults from March to mid-July 2020. Policies to improve health care affordability and to reassure
individuals that they can safely seek care may be necessary with surging COVID-19 case rates.

JAMA Network Open. 2021;4(1):e2034882. doi:10.1001/jamanetworkopen.2020.34882

Introduction

During the initial months of the coronavirus disease 2019 (COVID-19) pandemic, the US health care
system experienced major disruptions, with temporary closures of medical practices, cancellation of
elective procedures, and the shift of many services to telehealth delivery.1 These disruptions may
have led individuals to forgo medical care. Forgoing care for chronic and emergent conditions can
lead to increased complications and costs. Additionally, missing preventive care, such as cancer
screenings, can result in a delayed diagnosis. Since the pandemic onset, hospitals have reported
substantial declines in emergency department (ED) visits for severe health issues, including heart
attacks and strokes.2

Several factors may have influenced individuals’ decisions to forgo medical care during the
COVID-19 pandemic. In March 2020, many state and local governments issued emergency public
health orders, such as stay-at-home orders and bans on elective procedures, which either
discouraged or prohibited certain types of medical care.1 These suspensions were not lifted until late
spring or early summer 2020. Furthermore, many medical practices voluntarily closed in the early
weeks of the pandemic, either to redirect their personnel to COVID-19 response or to reduce risk of
transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that
causes COVID-19. Many individuals feared that seeking in-person medical care could expose them to
SARS-CoV-2.

In addition, the financial downturn caused by the COVID-19 pandemic increased unemployment
rates and reduced employee working hours. In the first 4 months of the pandemic, more than 48
million individuals filed for unemployment benefits.3 Because health insurance is tied to employment
for many US adults, layoffs have also resulted in more than 12 million individuals losing coverage since
March 2020.4 Resulting financial concerns may have influenced individuals’ decisions to obtain or
forgo care.

Several studies have sought to quantify changes in medical care during the pandemic using
electronic health record (EHR) or insurance claims data. A study by Westgard et al5 found a 49%
decline in ED visits comparing visits in the 28 days before and 28 days after the state emergency
declaration using EHR data from an urban trauma center.5 Using data from 9 cardiac catheterization
laboratories, a study by Garcia et al6 estimated a 38% decline in cardiac catheterizations, comparing
data from March 2020 with data from 2019 and earlier in 2020. Similarly, a study by Bhatt et al7

estimated a 43% reduction in hospitalizations for cardiovascular conditions in March 2020
compared with March 2019, using data from a large health system. While these studies provide a
useful snapshot of changes in health care utilization, they do not provide a nationally representative
picture of forgone care or assess the mechanisms behind reductions in care. Understanding reasons
individuals forgo care is particularly important for designing clinical and policy interventions targeted
to barriers to obtaining care. Furthermore, these prior studies focused on care for severe health
issues and did not examine preventive care, mental health care, or prescription medication
continuity.

To our knowledge, no published research has quantified the frequency of and factors associated
with forgone medical care during the initial phase of the COVID-19 pandemic in a representative
sample of US adults. We fielded a nationally representative survey to determine the frequency and
types of forgone medical care among adults and the reasons identified for cancelling or not seeking
care from March through mid-July 2020. We examined the sociodemographic characteristics of

JAMA Network Open | Health Policy Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

JAMA Network Open. 2021;4(1):e2034882. doi:10.1001/jamanetworkopen.2020.34882 (Reprinted) January 21, 2021 2/11

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respondents forgoing medical care and assessed whether prevalence differed for certain at-risk
groups, including individuals who were unemployed, lacked health insurance, or had chronic health
conditions. Finally, we examined 2 specific reasons respondents may have forgone medical care: fear
of exposure to SARS-CoV-2 and the financial repercussions of the COVID-19 pandemic.

Methods

All data reported in this survey study come from wave 2 of the Johns Hopkins COVID-19 Civic Life and
Public Health Survey, fielded July 7 to 22, 2020, using the National Opinion Research Center’s
(NORC) AmeriSpeak Panel. Prior to enrolling individuals in the AmeriSpeak Panel, NORC obtained
written informed consent. This study was approved by the Johns Hopkins Bloomberg School of
Public Health institutional review board. This study is reported following the American Association
for Public Opinion Research (AAPOR) reporting guideline.

The AmeriSpeak Panel is a probability-based panel designed to be representative of the US
adult population. The panel is drawn from NORC’s area probability sample and US Postal Service
addresses and covers 97% of US households.8 The AmeriSpeak panel’s recruitment rate is 34% and
includes approximately 35 000 individuals. Our sample was drawn from this panel, and respondents
completed the survey online.

We developed a 16-item module to assess health status and forgone medical care from March
to the time of survey data collection in July 2020 (eAppendix in the Supplement). Possible types of
forgone medical care included missed prescription medications, missed scheduled preventive care
visits, missed scheduled general medical outpatient visits (ie, physical health care, other than
preventive care, delivered in an office setting), missed scheduled mental health outpatient visits,
missed elective surgical procedures, or emergent health issues warranting general medical or mental
health care for which the respondent did not receive care. In the survey, we asked respondents to
distinguish between care received through telehealth (not classified as forgone care) and missed or
forgone care. We defined a new health issue as severe if a respondent reported a severity score of 4
or 5 on a 5-point Likert scale. In addition to the aggregate measure that included all of the categories
of forgone care, we also developed a measure of forgone planned medical care that included
prescription medications, scheduled preventive care visits, scheduled general medical outpatient
visits, scheduled mental health outpatient visits, and elective surgical procedures but did not include
new health issues.

We calculated prevalence of forgone medical care overall and by type of care among all
respondents and among the subset who reported needing care. Then, among individuals who
reported needing care, we calculated prevalence of forgone medical care by sociodemographic and
clinical characteristics and tested whether group differences were statistically significant. We also
analyzed group differences based on race/ethnicity, as the COVID-19 pandemic has
disproportionately affected Black, Hispanic, and Indigenous communities.9-11 We classified individual
race/ethnicity based on self-reported race/ethnicity using response options defined by NORC. Finally,
we tested whether frequency of forgone medical care differed by employment and health
insurance status.

Statistical Analysis
All counts and percentages reported in this study are survey weighted To test whether frequency of
forgone medical care differed between subgroups, we used Pearson χ2 tests. We considered a
difference to be statistically significant if the 2-sided P value was less than .05. We conducted
analyses in Stata statistical software version 16 (StataCorp), applying survey weights to calculate
nationally representative estimates. Data were analyzed from July 30 to September 3, 2020.

JAMA Network Open | Health Policy Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

JAMA Network Open. 2021;4(1):e2034882. doi:10.1001/jamanetworkopen.2020.34882 (Reprinted) January 21, 2021 3/11

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Results

Of 1468 individuals who completed wave 1 of the survey (70.4% completion rate), 1337 completed
wave 2 (91.1% completion rate). Among 1337 wave 2 respondents, 691 (52%) were women, and the
mean (SE) age was 48 (0.78) years. A total of 840 respondents (63%) reported their race/ethnicity
as non-Hispanic White, 160 respondents (12%) reported their race/ethnicity as non-Hispanic Black,
223 respondents (17%) reported their race/ethnicity as Hispanic, and the remaining 115 respondents
(9%) reported another race and non-Hispanic ethnicity (eTable in the Supplement).

A total of 544 respondents, representing an estimated 41% of US adults , reported forgoing
medical care during the initial phase of the COVID-19 pandemic in the US from March through
mid-July 2020 (Figure 1), including 108 respondents (8%) who reported missing 1 or more doses of
a prescription medicine typically picked up from a retail pharmacy, 387 respondents (29%) who
reported missing a preventive care visit, 343 respondents (26%) who reported missing an outpatient
general medical appointment, 105 respondents (8%) who reported missing an outpatient mental
health appointment, 77 respondents (6%) who reported missing an elective surgery, and 38
respondents (3%) who reported not receiving health care for a new severe mental or physical
health issue.

Among 1055 respondents (79%) who reported needing care from March to mid-July 2020, 544
(52%) reported forgoing care, including 108 of 725 respondents (15%) who typically picked up
prescription medication and who missed 1 or more doses, 387 of 664 respondents (58%) with
scheduled preventive care, 343 of 688 respondents (50%) with scheduled general medical care, and
105 of 227 respondents (46%) with scheduled mental health care reporting missing visits. Among
127 respondents who had scheduled an elective surgical procedure in the initial phase of the
pandemic, 77 respondents (60%) reported forgoing their surgical procedure. Finally, 38 of 74
respondents (51%) with a severe mental or physical health issue that emerged after the start of the
pandemic reported forgoing care.

Among 535 respondents who reported missing any planned medical care, including missed
prescription medications or missed scheduled appointments or procedures, 337 (63%) attributed
missed care to a medical practice being closed (either temporarily or permanently), 307 (57%)
attributed missed care to fear of SARS-CoV-2 exposure, and 75 (7%) attributed missed care to
financial repercussions of the COVID-19 pandemic (Figure 2). While medical practice closure was the
most common reason for missing care, 174 respondents (56%) who reported missing care owing to

Figure 1. Share of Respondents Forgoing Medical Care From March Through Mid-July 2020

0

Survey respondents, %
40 60 8020

Any forgone care

Prescription medication

Scheduled preventive care

Scheduled general medical appointment

Scheduled mental health appointment

Scheduled elective surgery

New severe issue

Overall Among individuals who reported needing care

Forgone medical care includes missing 1 or more doses
of a medicine the respondent typically picked-up or
had someone else pick-up from a retail pharmacy;
missing a scheduled health care visit, including a
preventive care visit, general medical outpatient visit,
mental health outpatient visit, or elective surgical
procedure; or not receiving care for a new severe
(defined based on self-report as severity 4-5 on a scale
of 1-5) physical or mental health issue. Individuals
could report multiple types of forgone care during the
period of March through mid-July 2020.

JAMA Network Open | Health Policy Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

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fear of SARS-CoV-2 exposure and 39 respondents (52%) who reported missing planned care owing
to the financial repercussions of the COVID-19 pandemic did not report medical practice closure as a
reason for forgoing care.

Among 108 respondents reporting a missed dose of medication, 44 respondents (41%)
attributed it to fear of COVID-19 and 23 respondents (21%) cited financial repercussions of the
COVID-19 pandemic. Among 387 respondents who reported missing scheduled preventive care,
scheduled general medical care, or scheduled mental health care, more than half of respondents
attributed the missed care to practice closure and fear of COVID-19 exposure, and less than 10% of
respondents attributed the forgone care to financial concerns owing to COVID-19 (Figure 2). Practice
closure and fear of SARS-CoV-2 transmission were also the most common reasons reported for
missing a scheduled elective surgery; more than one-quarter of respondents reported the financial
repercussions of the COVID-19 pandemic as a reason for forgoing elective surgery (Figure 2).

While the proportion of respondents reporting forgone medical care did not vary by sex,
differences were found by race/ethnicity, age, household income, employment status, and health
insurance status (Table 1). A larger share of Hispanic respondents reported missed prescription
medications compared with non-Hispanic White respondents (33 of 109 respondents [30%] vs 50
of 482 respondents [10%]; P = .004). Compared with adults aged 65 years or older, higher
proportions of respondents reported missed medication in age groups 18 to 34 years (45 of 204
respondents [22%] vs 10 of 160 respondents [6%]; P = .004) and 35 to 49 years (29 of 182
respondents [16%]; P = .01). Respondents in households with lower incomes (ie, <$35 000/year) more often reported missing medication compared with respondents in households with an income of $35 000 to $74 999 per year (66 of 244 respondents [27%] vs 26 of 226 respondents [12%]; P = .01).

Respondents who were unemployed or not working owing to disability, compared with
individuals who were employed, reported higher frequency of any forgone medical care (121 0f 186

Figure 2. Reasons Reported for Forgoing Care Among Respondents Who Missed Planned Care
From March Through Mid-July 2020

0
Survey respondents, %
40 60 8020

Missed any planned care (n = 535)

Missed ≥1 dose of prescription medication (n = 108)

Missed a scheduled preventive care appointment (n = 387)

Missed a scheduled general medical appointment (n = 343)

Missed a scheduled mental health appointment (n = 105)

Missed a scheduled elective surgery (n = 77)

Practitioner’s office being closed

Reported reason for forgoing care

Fear of SARS-CoV-2 exposure

Financial repercussions of COVID-19 pandemic

Respondents were prompted to select the reasons
that best described why they missed taking a dose(s)
of medication or missed a previously scheduled health
care appointment. Respondents were allowed to
select more than 1 reason. Practitioner practice being
closed was not a response option for individuals who
reported missing a dose of prescription medication.
COVID-19 indicates coronavirus disease 2019; SARS-
CoV-2, severe acute respiratory syndrome
coronavirus 2.

JAMA Network Open | Health Policy Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

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respondents [65%] vs 251 of 503 respondents [50%]; P = .01), missed doses of prescription
medication (46 of 117 respondents [39%] vs 46 of 367 respondents [13%]; P < .001), and missed scheduled medical care (111 of 159 respondents [70%] vs 225 of 405 respondents [56%]; P = .02). Compared with individuals with commercial health insurance or Medicare, those insured through Medicaid reported higher frequency of missed prescription medications (41 of 114 respondents [36%] vs 52 of 517 respondents [10%]; P < .001).

Frequency of forgone medical care varied by self-reported health status, number of prescription
medications taken, and presence of a mental health condition (Table 2). Respondents who rated
their health as fair or poor more often reported missing prescription medication compared with
individuals who rated their health as excellent (35 of 149 respondents [24%] vs 5 of 41 respondents
[11%]; P = .03), and those with 1 or more prescriptions reported forgoing any medical care less often
than those with no prescription medication use (443 of 902 respondents [49%] vs 99 of 149
respondents [66%]; P = .005). Similarly, individuals with a mental health condition more often
reported missing medication than individuals without a mental health condition (49 of 184
respondents [26%] vs 59 of 541 respondents [11%]; P = .004). No differences were detected in

Table 1. Respondents Who Reported Needing Care Reporting Forgone Medical Care From March Through Mid-July 2020, by Sociodemographic Characteristics

Characteristic

Any forgone medical care (N = 1055)a Missed dose of medicine (n = 725) Missed scheduled medical care (n = 873)b

No./total
No. (%) 95% CI, % P value

No./total
No. (%) 95% CI, % P value
No./total
No. (%) 95% CI, % P value

Sex

Men 234/458 (51) 44.9-57.1 [Reference] 41/299 (14) 9.0-20.4 [Reference] 211/384 (55) 48.5-61.5 [Reference]

Women 310/597 (52) 46.3-57.7 .81 66/426 (16) 10.3-22.9 .66 290/490 (59) 52.8-65.2 .38

Race/ethnicity

White, non-Hispanic 356/697 (51) 46.1-56.0 [Reference] 50/482 (10) 7.0-15.2 [Reference] 337/600 (56) 50.8-61.4 [Reference]

Black, non-Hispanic 58/121 (48) 36.1-60.1 .65 18/81 (22) 11.3-37.7 .06 48/85 (56) 43.7-68.3 .98

Other, non-Hispanic 48/94 (51) 35.9-66.3 .99 7/52 (13) 2.8-43.0 .78 39/70 (57) 38.9-72.9 .96

Hispanic 82/143 (57) 45.1-69.0 .34 33/109 (30) 16.7-48.6 .004 77/119 (64) 50.7-76.0 .27

Age group

≥65 125/262 (48) 41.4-54.2 [Reference] 10/160 (6) 3.4-11.4 [Reference] 119/231 (51) 44.5-58.1 [Reference]

50-64 155/276 (56) 48.9-62.6 .09 23/179 (13) 7.7-20.5 .08 146/242 (61) 52.9-67.6 .07

35-49 125/241 (52) 44.6-59.4 .39 29/182 (16) 10.3-24.5 .01 116/199 (58) 50.1-66.2 .19

18-34 139/276 (50) 39.3-61.6 .68 45/204 (22) 12.2-36.6 .004 120/202 (59) 45.8-71.7 .29

Household income, per y

<$35 000 167/327 (51) 42.6-59.6 .94 66/244 (27) 18.0-38.3 .01 149/264 (56) 46.4-65.7 .96

$35 000-$74 999 177/344 (52) 44.1-58.9 [Reference] 26/226 (12) 6.6-19.6 [Reference] 163/288 (57) 49.1-63.8 [Reference]

≥$75 000 200/384 (52) 46.1-57.7 .93 16/255 (6) 3.7-9.9 .09 189/321 (59) 52.3-65.1 .65

Employment status

Currently employed 251/503 (50) 43.9-55.9 [Reference] 46/367 (13) 8.4-18.7 [Reference] 225/405 (56) 49.0-61.9 [Reference]

Unemployed or not working
owing to disability

121/186 (65) 55.2-73.7 .01 46/117 (39) 25.1-55.2 <.001 111/159 (70) 60.0-78.3 .02

Retired or providing unpaid
family caregiving

129/271 (48) 41.3-54.2 .63 8/161 (5) 2.3-11.4 .05 125/239 (52) 45.3-59.1 .50

Insurance coverage

Commercial or Medicare 387/768 (50) 46.1-54.8 [Reference] 52/517 (10) 7.0-14.0 [Reference] 360/645 (56) 51.1-60.3 [Reference]

Medicaid 86/142 (61) 44.4-75.4 .23 41/114 (36) 20.0-55.7 <.001 75/116 (65) 45.1-80.4 .37

Uninsured 45/88 (50) 35.4-65.5 .99 12/56 (21) 9.5-40.9 .09 40/61 (65) 48.3-79.3 .28

a Forgone medical care includes missing 1 or more doses of a medicine the respondent
typically picked-up or had someone else pick up from a retail pharmacy; missing a
scheduled health care visit, including a preventive care visit, general medical
outpatient visit, mental health outpatient visit, or elective surgical procedure; or not
receiving care for a new severe (defined based on self report as severity 4-5 on a scale
of 1-5) physical or mental health issue. Individuals could report multiple types of
forgone care.

b Scheduled medical care includes scheduled preventive care visits, scheduled general
medical outpatient visits, scheduled mental health outpatient visits, and elective
surgical procedures.

JAMA Network Open | Health Policy Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

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reported frequency of forgone medical care by other chronic health conditions examined, including
heart disease, lung disease, or high blood pressure, diabetes, or high cholesterol.

We identified differences in the reasons stated for forgoing medical care by employment and
health insurance status (Figure 3). Compared with adults who were employed, adults who were
unemployed more often attributed forgone medical care to fear of SARS-CoV-2 exposure (78 of 186
respondents [42%] vs 120 of 503 respondents [24%]; P = .002) and to financial repercussions of the
pandemic (36 of 186 respondents [20%] vs 28 of 503 respondents [6%]; P = .001). Respondents
without insurance reported forgoing medical care owing to financial concerns more often than
respondents with commercial or Medicare health care coverage (19 of 88 respondents [22%] vs 32
of 768 respondents [4%]; P < .001). Respondents with Medicaid coverage, compared with respondents with commercial or Medicare coverage, more often reported forgoing care owing to concerns about SARS-CoV-2 exposure (70 of 142 respondents [50%] vs 203 of 768 respondents [26%]; P = .003) and financial concerns (21 of 142 respondents [15%] vs 32 of 768 respondents [4%]; P = .03). We also examined whether there were differences in reporting forgoing care owing to practice closures, but did not find statistically significant differences based on employment status or insurance coverage.

Table 2. Share of Respondents Who Reported Needing Care Who Reported Forgone Medical Care From March Through Mid-July 2020, by Clinical Characteristics

Characteristic
Any forgone medical care (N = 1055)a Missed dose of medicine (n = 725) Missed scheduled medical care (n = 873)b
No./total
No. (%) 95% CI, % P value
No./total
No. (%) 95% CI, % P value
No./total
No. (%) 95% CI, % P value

Self-reported health

Excellent 56/92 (61) 46.0-74.7 [Reference] 5/41 (11) 2.8-3.4 [Reference] 56/82 (69) 53.4-81.0 [Reference]

Very good 173/363 (48) 41.8-53.8 .11 25/254 (10) 5.7-16.3 .88 167/298 (56) 49.3-62.5 .13

Good 198/391 (51) 43.7-57.7 .21 43/281 (15) 9.6-23.1 .21 174/322 (54) 45.9-61.7 .09

Fair or poor 116/210 (56) 45.1-65.5 .54 35/149 (24) 13.0-39.4 .03 104/172 (61) 50.7-69.9 .36

Uses ≥1 prescription
medications

No 99/149 (66) 55.4-75.7 [Reference] NA NA NA 95/145 (65) 54.1-75.0 [Reference]

Yes 443/902 (49) 44.7-53.6 .005 108/725 (15) 11.0-19.7 NA 404/725 (56) 50.8-60.6 .12

Has high blood pressure,
diabetes, or high cholesterol

No 337/650 (52) 46.1-57.6 [Reference] 71/433 (16) 10.8-23.8 [Reference] 309/519 (60) 53.1-65.7 [Reference]

Yes 207/405 (51) 45.4-56.7 .85 37/292 (13) 8.5-18.4 .37 192/354 (54) 48.0-60.1 .23

Has heart disease, such as a
heart attack, coronary heart
disease, angina, congestive
heart failure, or other heart
problems

No 500/979 (51) 46.7-55.5 [Reference] 94/675 (14) 10.0-19.0 [Reference] 463/803 (58) 52.8-62.2 [Reference]

Yes 44/76 (58) 44.9-70.1 .33 13/50 (27) 13.0-47.4 .10 38/70 (55) 41.2-67.5 .69

Has lung disease, such as
chronic bronchitis or
emphysema

No 515/1003 (51) 47.0-55.7 [Reference] 103/695 (15) 10.9-20.0 [Reference] 475/829 (57) 52.5-61.9 [Reference]

Yes 29/52 (56) 39.7-71.0 .59 4/30 (14) 5.8-29.4 .86 26/44 (59) 43.0-73.1 .85

≥1 Mental health conditions

No 402/809 (50) 45.1-54.3 [Reference] 59/541 (11) 7.6-15.4 [Reference] 373/669 (56) 50.6-60.8 [Reference]

Yes 142/246 (58) 48.2-66.7 .13 49/184 (26) 16.3-39.9 .004 128/204 (63) 53.0-71.1 .22

a Forgone medical care includes missing 1 or more doses of a medicine the respondent
typically picked-up or had someone else pick up from a retail pharmacy; missing a
scheduled health care visit, including a preventive care visit, general medical
outpatient visit, mental health outpatient visit, or elective surgical procedure; or not
receiving care for a new severe (defined based on self report as severity 4-5 on a scale
of 1-5) physical or mental health issue. Individuals could report multiple types of
forgone care.
b Scheduled medical care includes scheduled preventive care visits, scheduled general
medical outpatient visits, scheduled mental health outpatient visits, and elective
surgical procedures.
JAMA Network Open | Health Policy Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

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Discussion

This survey study found that in a population representative of the overall US adult population, 41%
of adults reported forgone care from March through mid-July 2020. Previous studies have found that
individuals sometimes chose to forgo care prior to the COVID-19 pandemic; for example, the Kaiser
Family Foundation estimated that in 2018, 13% of White individuals, 17% of Black individuals, and
21% of Hispanic individuals forwent care owing to cost.12 However, our results suggest that the
COVID-19 pandemic exacerbated the problem, with individuals reporting closed practitioner offices,
fear of exposure to SARS-CoV-2, and the financial repercussions of the pandemic as common reasons
for forgoing care during this period.

These national survey results are consistent with research using insurance claims and EHR data
that documented declines in the use of health care services to treat severe health issues during the
first several months of the COVID-19 pandemic within specific health systems.5-7 Our results extend
existing research on forgone medical care by quantifying changes at the national level, considering
a larger set of health care services, and examining the underlying reasons reported for forgoing care
during the initial phase of the pandemic.

The most common reason respondents reported for missing scheduled care was owing to office
closure. The Coronavirus Aid, Relief, and Economic Security (CARES) Act13 included $175 billion to
provide financial relief to medical practices and hospitals during the COVID-19 pandemic, and such
funding may have helped practices that initially closed to reopen after putting additional safety
precautions in place to prevent the spread of COVID-19. Proactive outreach from health care
practitioner offices to reschedule cancelled appointments through in-person care or telehealth may
help limit the long-term consequences of this forgone medical care. Telehealth can also help
individuals continue to receive health care when they are concerned about exposure to
SARS-CoV-2.14 States and the federal government have supported telehealth by temporarily
loosening licensing, electronic prescribing, and written consent laws.15-17 Additionally, many payers
have temporarily increased the types of services that can be delivered via telehealth and
reimbursement for telehealth services.18 Continuing to provide financial and regulatory support for
telehealth is important to ensure that practitioners offer this service for the duration of the
pandemic. However, older adults who are uncomfortable with technology and individuals with
limited internet connectivity may struggle to access or may be hesitant to use telehealth.19 It is
important for practitioners and insurers to support patient use of telehealth and to ensure that

Figure 3. Reasons Reported for Forgoing Planned Care Among Respondents Who Reported Needing Care
by Employment and Health Insurance Status

0
Survey respondents, %
40 60 8020

Currently employed

Unemployed or not working because of disability

Retired or providing unpaid family caregiving

Commercial insurance or Medicare

Uninsured

Medicaid

Currently employed
Unemployed or not working because of disability
Retired or providing unpaid family caregiving
Commercial insurance or Medicare
Uninsured
Medicaid

Fe
ar

o
f S

A
R

S-
Co

V
-2

ex
po

su
re

Fi
na

nc
ia

l r
ep

er
cu

ss
io

ns
o

f
CO

V
ID

-1
9

pa
nd

em
ic

P =.002

P =.39

P =.12

P =.003

P =.001

P =.03

P <.001

P =.03

Responses are based on the time period of March
through mid-July 2020, during the initial phase of the
coronavirus disease 2019 (COVID-19) pandemic in the
United States. SARS-CoV-2 indicates severe acute
respiratory syndrome coronavirus 2.

JAMA Network Open | Health Policy Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

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telehealth can be accessed using a variety of internet speeds and devices, for example by offering
audio-only (telephone) services.20,21

Among respondents who reported missing planned care, 14% reported the financial
repercussions of the COVID-19 pandemic as a reason for forgoing care, and among the subset who
reported missing prescription medication, nearly 1 in 4 respondents reported financial reasons for
missing medications. Several policies can offer better financial protection to patients experiencing
financial distress owing to the pandemic. Within the 38 states plus Washington, District of Columbia,
that have expanded Medicaid, enrollment in Medicaid can improve health care affordability for
individuals who have lost health insurance or were uninsured when the pandemic began. The $600
boost to weekly unemployment benefits during the first 4.5 months of the pandemic may have also
mitigated some of the potentially harmful financial outcomes of the COVID-19 pandemic on people
with health care needs. More individuals who are unemployed may forgo medical care as their
unemployment benefits expire. Our results suggest that Medicare had a protective association, with
older adults reporting much lower frequency of missed medication compared with other age groups.
Conditioning businesses’ relief payments on keeping furloughed employees enrolled in their health
insurance is another strategy that may prevent forgone care owing to cost concerns. Employers
receiving federal assistance, such as the employee retention tax credit, are currently allowed, but not
required, to pay for health insurance for furloughed employees.22

Limitations
This study has several limitations. First, our sample size may have inhibited our ability to detect
statistically significant differences in the frequency and reasons of forgone medical care, particularly
when analyzing certain subgroups. Second, there may have been heterogeneity in responses to the
COVID-19 pandemic owing to differences in timing and extent of the pandemic and public health
responses in different locales not captured in our survey. Third, our survey items on forgone medical
care were generated for this study, preventing us from directly comparing our findings with
frequency of forgone medical care before the COVID-19 pandemic. Fourth, the AmeriSpeak panel
used probability-based recruitment aligning with best-practice survey research standards, but results
may be susceptible to sampling biases. Fifth, we did not have information on the employment or
health insurance status of a respondent’s entire household. If a family member lost employment or
health insurance owing to the pandemic, it could financially affect decision-making within the entire
household about whether to seek or forgo care. Sixth, our analysis did not capture all types of
forgone medical care; for example, we did not consider missed doses of mail-order drugs.

Conclusions

The findings of this survey study suggest that as the United States is experiencing another wave of
surging SARS-CoV-2 infections, it will be important to track whether interventions to enhance health
system safety provide the public with sufficient confidence to seek medical care. As emergency
financial measures enacted by the US Congress and unemployment benefits expire, ensuring the
affordability of needed health care services for individuals financially impacted by COVID-19 is
critical.

ARTICLE INFORMATION
Accepted for Publication: December 4, 2020.

Published: January 21, 2021. doi:10.1001/jamanetworkopen.2020.34882

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Anderson KE
et al. JAMA Network Open.

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Corresponding Author: Kelly E. Anderson, MPP, Department of Health Policy and Management, Johns Hopkins
Bloomberg School of Public Health, 624 N Broadway, Room 428, Baltimore, MD 21205 (kelly.anderson@jhu.edu).

Author Affiliations: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public
Health, Baltimore, Maryland.

Author Contributions: Ms Anderson had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Anderson, McGinty, Barry.

Drafting of the manuscript: Anderson.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Anderson.

Obtained funding: McGinty, Barry.

Administrative, technical, or material support: McGinty, Barry.

Supervision: McGinty, Barry.

Conflict of Interest Disclosures: Ms Anderson previous employment from The Lewin Group outside the
submitted work. No other disclosures were reported.

Funding/Support: The Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins University
Alliance for a Healthier World’s 2020 COVID-19 Launchpad Grant funded data collection. The Agency for
Healthcare Research and Quality provides tuition and stipend support for Ms Anderson (grant No.
T32HS000029). The National Institute of Mental Health provides tuition and stipend support for Ms
Presskreischer (grant No. T32MH109436).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.

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SUPPLEMENT.
eAppendix. Question Wording for Forgone Medical Care, Health Insurance, and Employment Survey Questions
eTable. Characteristics of Study Sample

JAMA Network Open | Health Policy Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

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