By Augie Lindmark, M.D.
The Nation, May 21, 2020
Lately my work in the hospital consists of two activities. Admit patients with Covid-19, and, if lucky, discharge patients with Covid-19. The work is monotonous. But then the loudspeakers click on and Andra Day’s “Rise Up” plays throughout the hospital, and for a moment I’m transported away from the oxygen tubes and ventilators. Someone with Covid-19 is going home. The melody offers hope, but that quickly disappears.
A couple of months ago—before all my patients had Covid-19—Peter arrived at the emergency room gasping for air. A severe asthma exacerbation had grabbed his lungs and wouldn’t let go. Peter was intubated, stabilized, and sent to the ICU. The first crisis was avoided.
The second crisis began the following day, within minutes after he was extubated. His nurse paged me: “Patient is distressed. He’s leaving ASAP.” I walked into the room and saw Peter breathing quickly, but asthma was no longer the culprit. “Do you have monthly payment plans?” he asked. His eyes held a familiar fear of uncertainty, of normalcy slipping away. Like millions of Americans, Peter was uninsured. He wanted to leave because of his mounting medical bills.
Each day I spend in the hospital now I hear that Andra Day song. With mounting Covid-19-related deaths I need some source of hope. But when I know patients are expelled back into an unreliable health care system, one that is notorious for financial ruin, celebration feels misplaced.
Far before SARS-CoV-2 dominated news cycles and hospitals alike, there were already established epidemics in US health care: namely, medical bills and uncertainty. In 2019, a third of US adults reported that their families couldn’t afford health care and 44 percent endorsed skipping a doctor’s visit because of cost. Medication affordability wasn’t much better: 29 percent of adults reported not taking a medication as prescribed due to cost.
Enter: Covid-19. You could almost hear the virus salivate.
When this coronavirus arrived in the United States, and when Donald Trump downplayed a pandemic while tests were delayed, the confusion over whether health insurance would cover testing and treatment began. The public needed confirmation that testing and treatment was accessible and affordable. Instead, Trump did what Trump does: make empty promises and baseless claims.
In a White House address on March 11, Trump incorrectly claimed the commercial health insurance industry “agreed to waive all copayments for coronavirus treatments.” He then doubled down and falsely said surprise medical bills—charges that come from out-of-network providers—would also be canceled for Covid-19. Surprise bills were not eliminated, and they still are not.
A spokesperson for America’s Health Insurance Plans (AHIP), the leading US health insurance lobby group, quickly corrected the president that the waivers were, “For testing. Not for treatment.” The beneficence of insurers, if we want to call it that, had its limits. In the president’s defense, dictating to hundreds of health insurers what they should cover outside of preventive care should be possible, but, in our current system, is a laughable proposition.
Still, testing coverage, though far from adequate, was a start. But then parsing began: What constituted coverage? Did that insurance coverage include doctor visits? Ancillary lab tests typically ordered with a Covid-19 test? Stories of Covid-19-related medical bills continued to mount, from ambulance rides to lab tests to medications. In one case reported by NBC News, a patient who recovered from Covid-19 faced over $3,000 in bills. He lamented he would have to “duke it out with my insurance company.”
Four months after the first confirmed case of Covid-19 in the US, most large health insurers now offer some form of cost-sharing waiver for Covid-19 treatment, in addition to testing. The Families First Coronavirus Response Act and the CARES Act expanded coverage for testing and treatment, but universal coverage for Covid-19 care has yet to be established.
But many large health insurers that offered fee waivers for Covid-19 treatment also set expiration dates by June 1, meaning treatment after that date wouldn’t be included, according to a recent report from Public Citizen. Furthermore, of the 25 largest health insurers, only two state that they will cover care for out-of-network providers, which opens the door to surprise medical bills.
“Insurers that are swimming in cash are trying to get credit for doing the bare minimum during an unprecedented health crisis,” said Eagan Kemp, lead author of the Public Citizen report. He further described the waivers as full of “caveats, confusing restrictions and premature end dates.”
If there’s a medical condition that would force people otherwise resistant to seeking medical care into the health system, a deadly virus is one of them. But not even Covid-19 has wiped away hesitation borne of financial fear. Last month, a Gallup poll reported that 14 percent of Americans would avoid health care due to cost if they developed symptoms of Covid-19. This number was higher among low-income individuals and people of color. Testing, contact tracing, social distancing, and treatment are all important components of pandemic responses. But the efficacy of these tools is blunted by a splintered health system that bars easy access to health care.
Perhaps the greatest risk of this pandemic is that we’ll come out on the other side with an unchanged health care system—one that causes harm. There is nothing normal about Kaiser Health News and NPR reporting a “Bill of the Month,” a recurring series on astronomical medical bills sent to unsuspecting patients. There is nothing normal about Equifax constructing a FAQ about how to negotiate your Covid-19 medical bill, which concludes by saying “Don’t forgo treatment to prevent a hospital bill; your health is too important.” There is nothing normal about staggering medical bills.
As political officials begin “reopening” public spaces and relaxing social distancing, the various forms of medical distancing placed on patients, from copays to surprise medical bills, must also be addressed—and not just for Covid-19. When uncertainty and medical bills no longer prevent health care, maybe then I’ll feel like celebrating.
Dr. Augie Lindmark is a physician and writer based in New Haven, Conn.