At the stroke of midnight last Tuesday, the US government stopped covering the cost of Covid-19 testing and treatment for the uninsured. Funding for the Covid-19 Uninsured Program, established at the outset of the pandemic, had run dry, and Congress had failed to replenish it. The uninsured can now be subject to ruinous medical bills after a Covid-19 hospitalization, a threat that will surely drive some to avoid seeking care; notably, one testing company has said it plans to charge uninsured patients $125 per Covid-19 test, a fine that will deter testing and hence disease control efforts. In two weeks, Covid-19 vaccine administration for the uninsured will also no longer be reimbursable, likely reducing timely access to vaccination. With yet another pandemic wave looming on the horizon, the evaporation of support for a disadvantaged population at elevated risk of Covid-19 could worsen the spread and impact of this virus.
Two years ago, as Covid-19 first swept my state, my primary focus as a critical care physician was clinical work. I was seeing waves of patients with severe Covid-19 pneumonia fill the ICU of the safety net Boston-area hospital where I still work today. But being a health care researcher as well, I worried about how our nation’s fragmented, inequitable health care system would cope with the pandemic. With some 30 million Americans uninsured, and even more underinsured, I feared that high deductibles and copays would deter patients with respiratory symptoms from SARS-CoV-2 testing and delay their care—inadvertently contributing to viral spread and severe outcomes from this new disease. Though that outcome was attenuated by unprecedented measures taken by governments and insurers, we’re now inching toward a worst-case scenario. While it’s true that it has always been arbitrary to institute universal health care for one illness, we ought to be pushing toward greater universality instead of retreating from it; American health care should become more like Covid-19 care rather than the reverse. Indeed, without change, the latter will be rationed by ability to pay at a moment when treatment breakthroughs have made the need for speedy access to medical care more urgent than ever.
In the spring of 2020, it seemed unlikely that the government would put into place so many provisions to finance pandemic care. An April poll found that about 1 in 10 Americans would avoid care because of costs even if they believed they had Covid. My earliest Covid-19-focused research study estimated that nationwide some 18 million Americans at increased risk of severe Covid-19 due to advanced age or medical conditions were uninsured or underinsured. Nonetheless, the federal government outperformed my cynical expectations and took important if inadequate actions to provide semi-universal coverage for this specific illness. The Families First Coronavirus Response Act, expanded by the CARES Act, required full coverage of Covid-19 testing by insurers, and provided funds (now depleted) for testing and treatment of uninsured Covid-19 patients. Thus far, some $18 billion has been paid out for Covid-related care for the uninsured, including an average of $360 per uninsured person for Covid-19 testing. The federal government would later also directly purchase—and freely distribute—Covid-19 vaccines, and it took a similar approach with monoclonal antibodies and the new oral antiviral pills.
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Such measures have played an important role in making the Covid-19 medical response—particularly the vaccine rollout—more equitable than much else in American health care. To be sure, inequality remained: In another investigation, for example, colleagues and I demonstrated that in 2020 the uninsured were less likely to have a Covid-19 test than those with health coverage, yet faced a greater burden of infection. In a third study, we found that even accounting for differences in age, the uninsured were vaccinated more slowly than those with health insurance, although vaccines were free—perhaps because they lacked an established relationship with a health care provider who might help address their concerns, or feared costs given past experiences. Work by others produced further evidence that America’s inequitable health care system hampered our Covid-19 response: County-level primary care physician density is tied to vaccine rates, even with control for various factors such as political orientation. Still, there is little doubt that absent expanded government coverage and support for Covid-19 care, things would have been infinitely worse.
But today, the stakes of this issue are higher than ever. At the start of the pandemic, outpatient treatment options for Covid-19 were so limited that most of it was really just triage: determining, for instance, who could stay home, and who should be evaluated in an emergency room or hospitalized. And for those of us caring for Covid-19 patients in hospital wards or ICUs, treating Covid-19 initially meant the (complex) provision of respiratory support and management of complications as they arose: There were no specific Covid-19 drugs. But things have changed: We soon learned that the use of the steroid dexamethasone prevented deaths among those needing oxygen for Covid-19 pneumonia; it is plausible that delayed initiation of such an agent could worsen outcomes for some who stay home despite low oxygen levels. Other drugs that tamp down the immune system in severe Covid-19 have also been found to save lives. Other work found mixed evidence of benefit for the intravenous antiviral drug remdesivir, perhaps because the benefits only emerge when given early. But with out-of-pocket costs for Covid-19 hospitalizations averaging $4,000 for the privately insured, and with the uninsured losing all coverage for hospitalization, the sorts of financially driven delays in care we observe across the health care system (including in emergencies) could also keep patients from benefiting from prompt intervention for Covid-19.
Yet the issue is far more crucial when it comes to new antiviral therapeutics for Covid-19, which must be taken early when it is still a cold and not yet pneumonia resulting in hospitalization. Remdesivir, paxlovid, and monoclonal antibodies each, if given early enough, vastly reduce the risk of hospitalization for high-risk Covid-19 patients. And the benefits of booster vaccines in restoring waning protection for high-risk individuals are now beyond doubt. In other words, we have the technological means for an effective medical response to this virus. Yet, even as this knowledge has accumulated, efforts to build a robust infrastructure to deliver it are faltering. In addition to pulling out the rug from under the uninsured, deficient funding will undercut the broader medical response to Covid-19: The Biden administration has said funding inadequacies will limit further purchases of these antiviral agents and fourth doses of vaccines, for instance.
It is perhaps naive to think that a single disease would forever remain carved out of the profit-oriented logic of American health care, although these recent changes are even more abrupt than I would have predicted. Even if a compromise is reached and funding replenished in coming days, it will only be a (much needed) Band-Aid—a temporary and inadequate fix for a virus that is not going away, to a health care system whose deficiencies will continue to undercut our pandemic response without deeper reform. Make no mistake: Congress must take action to restore coverage for Covid-19 care for the uninsured, and to fund the broader pandemic medical response, today. But a universal medical response, achievable through realization of a comprehensive national health program, will be needed to combat Covid-19 for many years to come.