With more than 39,000 people dead and more than 738,000 infected with COVID-19 in the US, the last question on a person’s mind should be how they will pay for life-saving treatment.
Yet as the death toll mounted, a patient who was about to be put on a ventilator in one of New York City’s stretched-to-capacity intensive care units had a final question for his nurse: “Who’s going to pay for it?”
Those were the patient’s final words to his medical team.
Illustration: Yusha
Derrick Smith, a nurse anesthetist at a New York City hospital wrote on Facebook last week: “Next-level heartbreak — having to hear a dying patient use his last words to worry about healthcare finances.”
In the wealthiest country in the world, the COVID-19 pandemic has exposed the core of a healthcare system that is structurally incapable of dealing with it.
Federal and local governments, health insurers and employers have pledged to help Americans pay their way through this crisis, but to do so requires a dramatic overhaul of a system that has for decades prioritized cost over care.
“As this epidemic makes clear, at any moment, any of us could become sick, could become hospitalized, could be on a mechanical ventilator, and that, in the United States, could mean potentially ruinous healthcare costs,” said Adam Gaffney, an intensive care unit (ICU) doctor in Boston.
Gaffney is president of Physicians for a National Health Program (PNHP), a group of more than 20,000 medical professionals who support universal healthcare in the US.
PNHP members see firsthand the consequences of people being forced to make medical decisions based on cost.
“I’ve heard from patients saying they’ve skipped their inhaler because they couldn’t afford the dose,” Gaffney said. “I’ve heard from patients who’ve gone for years without primary care because they were uninsured and wound up in the ICU.”
There were 27.9 million Americans without health insurance in 2018 and that figure is projected to increase by millions because of record-high unemployment.
The US government and major health insurers said they are covering the costs of COVID-19 testing and treatment, but fear of bankrupting costs and the byzantine complexities of the system leave unanswered questions about whether people will even seek care, let alone escape a potentially crippling medical bill weeks or months later.
How much testing and treatment costs individuals depends on if the patient was insured, how they were insured and whether they survived.
For example, a company that pays for its staff’s health insurance could decide not to cover an employee’s treatment, even if the health insurance company it is using had said it would waive payments related to COVID-19.
Simply overcoming the American instinct to question how much medical treatment costs is also a hurdle in the pandemic.
Since 2006, 30 percent of Americans each year on average have delayed any sort of medical treatment for cost, the polling firm Gallup said in a report in December last year.
In that time, 19 percent of Americans each year on average have delayed treatment for a serious condition, the report said.
More Americans are afraid of paying for healthcare if they became seriously ill (40 percent) than are afraid of getting seriously ill (33 percent), a 2018 poll by the University of Chicago and the West Health Institute showed.
“It’s hard to fight an epidemic if people are afraid to go to the doctor, to be seen in the emergency room,” Gaffney said. “It could mean some people not getting tested; it could mean some people delaying getting care and potentially harming their own health.”
The pandemic crisis is being further exacerbated by the system’s devotion to profits over people. Medical workers are being furloughed and losing jobs because of the pandemic — including those on the front lines — as their employers seek to cut costs.
Alteon Health, a private equity-backed company that employs about 1,700 emergency medicine doctors and other physicians, said that it would temporarily stop providing benefits including paid time off, the health Web site STAT said.
While ICUs and emergency rooms are billing sky-high figures, there has been a pause on non-essential care that has, in turn, cut medical system profits.
Without high-margin treatments such as physical therapy, cosmetic surgery and orthopedic procedures, medical systems are struggling to pay salaries and cover administrative costs.
The American Academy of Family Physicians projected 60,000 family practices would close or significantly scale back by June and 800,000 of their employees would be laid off, furloughed or have their hours reduced.
In hospital corridors across the country, staff are not just extra mindful of a dry cough and high temperature, but also that their salaries and work equipment are dependent on the bottom line.
“The bottom line has always been very forefront and this now puts into an extra level of being conscious on our mind to not waste money,” said Joe Manginn, an emergency room nurse in Madison, Wisconsin.
Manginn and his wife, who is also a healthcare worker, are on alert for their own healthcare costs.
“If we do get sick and need to be hospitalized, it hits us financially with the insurance and those kinds of payments, but it also hits us financially because we’re not able to work any longer,” Manginn said. “It’s a double whammy for the healthcare workers doing this right now.”
His health insurance, which also covers their three children, costs US$5,000 a year plus the money they set aside for out-of-pocket costs in a tax-free account.
“We work for the hospital, it should be that we would have the most access to it [healthcare], but unfortunately yeah, that’s not how our country is set up,” he said.
The US Congress has allocated US$100 billion to help hospitals.
On April 10, the White House said hospitals that accept the funds would not be allowed to use two common billing practices: to bill uninsured patients or bill them for getting care from a doctor who is at the hospital, but not directly employed by it.
Like other parts of the planned government response, questions remain about just how effective that money will be in addressing the convoluted healthcare landscape and if it will arrive in time to save jobs and clinics.
This major disruption to the US healthcare system might leave nurses and doctors jobless, but there are early indications that insurance companies could be insulated from the damage.
Not only did health insurance companies enter the crisis with capital, several analysts have anticipated that these companies could have lower costs because fewer people are seeking routine medical care.
David Blumenthal, president of the global health think tank the Commonwealth Fund, said that people who have coverage year-round would still be paying premiums, while insurers would have fewer procedures to cover.
“We will continue to pay our premiums, because we know that we could get coronavirus and end up in the intensive care unit and have to pay hundreds of thousands of dollars if we don’t have insurance,” Blumenthal said. “So we’re going to keep paying, but we’re not going to the doctor unless we absolutely need to. So that’s all good news for insurance companies.”
At the same time, the 16 million people who have lost their jobs in the past three weeks would put an increased burden on the healthcare system if they join the ranks of the uninsured or those who use Medicaid, government health insurance for low-income earners.
Blumenthal said that there are also knock-on health effects to the economic crisis, such as depression from income loss and malnutrition, which would make people more susceptible to illness.
Benjamin Sommers, a professor of health policy and economics at Harvard T.H. Chan School of Public Health, said that there are few signs the pandemic is driving US President Donald Trump’s administration to reflect on the healthcare system.
“We’ll have to see where the public ends up settling on in terms of what it demands from public officials in response to this epidemic,” said Sommers, a practicing primary care physician.
Gaffne said that he was certain the way healthcare is financed in the US is exacerbating the overall damage of the epidemic.
“At a time of soaring unemployment and at a time of deepening recession, people are going to be losing coverage and seeing more and more medical bills if they get sick,” Gaffney said. “That doesn’t make any sense.”
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