Last month, Patti Hanks faced a wrenching decision: go back to her job, or lose her health insurance.

Ms. Hanks, 62, recently had ovarian cancer treatment. With her immunity low, she was nervous about returning to her workplace, a store where she would be drawing up financing plans and taking cash payments from customers buying furniture and large appliances.

But she was even more worried about losing her health coverage if she didn’t go back. Finding a job with health benefits that allowed her to work from home felt like a pipe dream in the midst of an economic downturn.

“I just got over chemo,” she said. “Now is not the time for me to lose my insurance.”

So, despite her reservations, she returned to work. She wears a mask and makes sure customers sit a good distance away at an L-shaped desk.

“It’s a scary thing to go back and know you have low immunity,” she said in mid-May, after two days back at her job. “But when it all boils down to it, I don’t think Covid-19 is going away any time soon. I don’t think you can hide from it. You’ve got to trust God and go back.”

Ms. Hanks’s experience illustrates how America’s employment-based health insurance system could become another liability in the country’s fight to contain coronavirus. It could push workers at highest risk of serious illness from coronavirus back to work the fastest. Those people need coverage to treat the pre-existing conditions that make them vulnerable in the first place.

About one-quarter of American workers — 37.7 million people in total — are estimated to be at high risk of serious illness from coronavirus, according to a Kaiser Family Foundation study published this week.

Some are at increased risk because of age, and some have health problems like diabetes or asthma that the Centers for Disease Control and Prevention has identified as risk factors.

“It is one of the many ways the U.S. health care system has made us so much more vulnerable to the effects of the pandemic than other countries,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation and a co-author of the new study. “In other countries, you don’t hear about people losing health insurance when they lose their jobs.”

When it comes to health care, the United States is rarely like the other countries Mr. Levitt mentions. In Canada and Britain, workers get their health coverage through the government. In many European countries, like Germany and the Netherlands, workers buy subsidized coverage individually in tightly regulated markets.

In the United States, 61 percent of working-age adults get health insurance through work. This system of employer-sponsored insurance dates to World War II-era policy decisions that encouraged companies to provide workers with medical benefits.

The federal government’s most consequential decision, in the mid-1940s, was to not tax health insurance benefits. An employer’s dollar spent on health benefits suddenly stretched much further than one spent on wages. This laid the groundwork for what we see today: Most companies, large and small, offer health benefits to workers.

The Affordable Care Act did provide new ways for Americans to get health insurance outside of work. It expanded Medicaid to cover millions more low-income adults. It also created new private insurance marketplaces where middle-income Americans could buy subsidized coverage (and health plans could not discriminate against those with pre-existing conditions).

But that new safety net has some holes. Fourteen states, including large ones like Florida and Texas, declined to participate in the health law’s Medicaid expansion. Workers who lose employer-sponsored coverage in those places may have less access to affordable coverage options.

Others may find the coverage options on the health law marketplaces prohibitively expensive, particularly those earning slightly too much to receive coverage subsidies. What’s more, the most affordable marketplace plans tend to provide less robust coverage than what employers typically offer. They require patients to pick up a greater share of their treatment costs with co-payments and deductibles.

Those shortfalls in the safety net may push vulnerable workers to do what Ms. Hanks did: go back to work before feeling entirely comfortable with the risks.

  • Updated June 16, 2020

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Ms. Hanks lives in Virginia, a state that expanded Medicaid, but she expects that she earns too much from other income sources to be able to sign up for the program. She and her husband (who is a few years older and covered by Medicare) own a few rental properties as well as a herd of Black Angus cattle, which they sometimes sell to meat producers or other farmers.

When the couple bought their own health coverage about a decade ago, before Obamacare, they could find only expensive options shopping on their own. Access to employer-sponsored coverage was one of the reasons Ms. Hanks took her job at the furniture store in the first place.

A month after returning to work, she generally feels safe. She and other employers sanitize their chairs and desks frequently. Ms. Hanks is careful to wipe down the pens her customers use to sign contracts.

She recently got some good news from her doctor: Her immune system seems to be recovering from the chemotherapy treatment, returning closer to normal.

Still, the store has been pretty busy since Virginia began lifting stay-at-home restrictions last month (demand for freezers appears to be especially high, possibly a sign of families stocking up on groceries). There was one episode that scared her, when a worker from a local nursing home entered the store to shop.

“She didn’t look like she felt good, like she was kind of sweaty on the forehead,” she said. “She had a mask on, but I was sitting there, looking at her, thinking this is not good.

“But you can’t crawl into a hole. I think we’ve done everything we can to protect ourselves. I know I try to. So I’ll just keep going. That’s just the way it is.”

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