For the Uninsured, COVID Care Has Entered a New Stage of Crisis

Mandy Alderman, whose difficulty getting care for COVID-19 has become an increasingly common problem for poor, uninsured Americans, in Lawrenceville, Ga., Nov. 13, 2022. (Audra Melton/The New York Times)

WASHINGTON — When Mandy Alderman caught the coronavirus in June for a second time, she hoped her usual primary care physician could prescribe a monoclonal antibody treatment or Paxlovid, the antiviral pill that has been shown to reduce the severity of an infection. But without health insurance, she could not afford a visit.

Alderman, 44, a former medical assistant in Lawrenceville, Georgia, found a doctor willing to prescribe a cocktail of other drugs, but not the proven COVID-19 medications she wanted. She took what she could get. She had to lean on her aunt for the $85 it cost to retrieve the drugs from a Publix grocery store pharmacy near her home.

“I felt like I was irrelevant,” Alderman said, recounting the ordeal. “I felt like I didn’t matter.”

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Difficulty getting care for COVID-19 has become an increasingly common problem for poor, uninsured Americans. After paying about $25 billion to health care providers over the course of the pandemic to reimburse them for vaccinating, testing and treating people without insurance, the federal government is running low on funds for COVID care for the nearly 30 million Americans who are uninsured.

The Biden administration is asking Congress to replenish its coffers, but its pleas to lawmakers this year have so far been unsuccessful. Warning about the threat of new subvariants as winter approaches, the White House asked Congress last month for more than $9 billion in additional funding for the pandemic response. Some of that money would go toward ensuring that Americans, including those without insurance, continue to have access to vaccines and treatments.

Republicans in Congress have resisted the White House’s requests. They have accused the administration of spending pandemic relief money in a wasteful manner and have shown little appetite for providing more funding, especially after President Joe Biden declared in September that “the pandemic is over.”

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Adding to the dilemma for the uninsured, the administration is planning to allow vaccines and treatments for COVID-19 to hit the commercial market by next summer — a move that could further hinder access for those without health coverage.

The result, public health experts say, is the end of the universal access that Americans have had to COVID care during the pandemic, a rare exception in the fragmented U.S. health care system. As federal funding dries up, people without insurance may be left footing the bill for tests and treatments, or they may be discouraged from seeking care altogether.

The problem is especially acute in states that have yet to expand Medicaid under the Affordable Care Act. Those areas, where Republicans partly or entirely control state government, tend to have a larger share of residents without health insurance than the states that have adopted the expansion.

“Because of COVID, we’ve been able to temporarily create a bright spot for care,” said Kody H. Kinsley, the top health official in North Carolina, one of the states that has not expanded Medicaid. He added, “That island is slowly vanishing.”

Michele Johnson, executive director of the Tennessee Justice Center, a legal aid group that helps poor residents in the state, which is one of those that has not adopted the expansion, warned that people without coverage were facing a new risk of COVID-induced medical debt.

“We’re back to the old ways,” Johnson said, adding, “People are going without vitally important services, and/or they’re going into debt for the rest of their lives.”

For much of the pandemic, the federal government covered the cost of vaccinating, testing and treating the uninsured through a fund run by the Department of Health and Human Services. But that program shut down in the spring because of a lack of funding, and in September, the government stopped providing free at-home tests through the Postal Service for the same reason.

Roughly 50,000 coronavirus cases — a figure that is almost certainly a significant undercount — are being reported in the United States each day, and people without insurance can face an array of costs. Bills for tests can be large and unpredictable; some people have faced charges of more than $3,000 for the routine nasal swab. For those who become seriously ill, a hospitalization can cost more than $1 million.

The government continues to offer COVID-19 treatments such as Paxlovid for free to patients. But without the federal uninsured fund, Americans without health coverage can still be charged for outpatient visits needed for a diagnosis or a prescription.

Once the government’s supply of treatments runs out, health care providers will need to buy them on their own, with insurers covering the costs for Americans just as they do for other treatments. People without coverage will in most instances pay for the drugs out of pocket. The same is true for coronavirus tests.

And with the prices of coronavirus vaccines expected to increase on the commercial market, the shots could eventually become less accessible to people without insurance. The federal government has purchased a large supply of the updated booster doses, but another round of shots is expected to be needed next year.

The Biden administration has proposed a new program called Vaccines for Adults that is modeled after a federal program that provides vaccines to children at no cost. If funded by Congress, the program would supply coronavirus shots and other vaccines while reimbursing providers for administration fees.

The government has also talked to manufacturers of vaccines and treatments about funding their own programs for the uninsured, Dawn O’Connell, the assistant secretary for preparedness and response at the Department of Health and Human Services, said at an event hosted by the Kaiser Family Foundation this fall.

“We’re trying to pull a few levers all at once,” she said.

In 15 states, a temporary federal provision allows Medicaid funds to be used to cover vaccine-related fees, treatments and tests for the uninsured. But that program will expire when the federal government lifts its declaration of a public health emergency for the pandemic, a move it could make as soon as next year.

The Biden administration has also experimented with a smaller program that could offer a template for future distribution methods. In September, weeks after an Eli Lilly monoclonal antibody treatment moved to the commercial market, the administration announced that it would make 60,000 doses available to health care providers. Each time a provider used a commercially purchased dose for an uninsured patient, the federal government offered to replace that dose. (The Food and Drug Administration said last week that the drug, which is not expected to work against newer coronavirus variants, was no longer authorized for emergency use.)

There were warning signs even before the federal uninsured fund lapsed of the hassles to come. Anthony Lund, a professional health insurance counselor who previously worked at a Mayo Clinic testing center in Minnesota, once offered reassurances to uninsured patients he scheduled for coronavirus tests: The federal government would pick up the cost.

But then Lund lost his own health insurance when he switched jobs and had to wait for his new benefits to kick in. With a fever and a runny nose in January, he suddenly needed a test at Mayo. A surprise bill arrived in May: $520 for the nasal swab.

“If we knew it was going to be charged, I wouldn’t have gone in for testing,” he said, recounting his shock.

Lund’s saga ended with persistence. After corresponding with the Mayo Clinic for weeks and citing the policies he had previously counseled others about, Lund got the testing bill dropped. A spokesperson for the clinic said it had reversed the charge as a courtesy to the patient.

The end of the uninsured fund has already led to a shrinking of the nation’s COVID infrastructure. In North Carolina, some privately run testing sites have closed in part because contractors could no longer bill the government for tests given to people without insurance, said Kinsley, the top state health official.

Providers in the state that relied on the fund are now left with few options. Resourceful Clinical Laboratory, which oversaw testing and vaccination sites in rural eastern North Carolina that predominantly served the uninsured, leaned heavily on federal reimbursement. The company no longer operates the sites, said Stephanie Tyson, its CEO.

The end of the fund has also added to the financial pressures on hospitals. Beth Feldpush, the senior vice president for policy and advocacy at America’s Essential Hospitals, which represents safety-net hospitals, said that hospitals that care for the uninsured had been left to balance the costs of treating those patients with rising salaries for nurses and administrative staff members.

As federal funding dwindles, Kinsley said the consequences were clear: COVID-19 was heading the way of illnesses like diabetes or high blood pressure.

“We’re going to be back in a place that unfortunately we know really well,” he said. “We’ll have people showing up in emergency departments that could have been handled with more access to prevention.”

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