The financial fallout of medical bills generated by COVID infections could be the next phase of the country’s pandemic disaster.
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When Gisela Moreno’s husband was released from a central California hospital in December 2020, following a three-week stay for complications caused by the coronavirus, his family was just grateful he was alive.
“We were so excited,” said Moreno. “I just hugged him. We gathered him in the car, and we were just so happy.”
Her husband, Jesús Gutiérrez, 46, had been admitted to Pioneers Memorial Hospital in Brawley, California, at the end of November. At that time, he struggled to breathe and stand on his own. While in the hospital, Gutiérrez’s lungs became inflamed, his oxygen levels plummeted, and he wasn’t able to see Moreno or the couple’s two teenage children.
“These were very troublesome times,” said Gutiérrez through a Spanish interpreter, “not knowing whether I was going to make it out alive or not.”
For months after his release, Moreno was dedicated to Gutiérrez’s rehabilitation. She devoted her days helping him bathe, get in and out of bed, and regain enough strength to walk on his own.
So when, on Gutiérrez’s suggestion, Moreno called the hospital to check if they had any outstanding bills, she wasn’t prepared for what she heard. For his stay — more than half of which was covered by Medi-Cal — the couple owed $83,385.10.
“I felt like, how are we gonna get through?” Moreno said. “How are we going to get that money? What are we going to do? It’s like a mortgage of a house. Like… how?
Moreno and Gutiérrez’s case isn’t unique. Since the onset of the coronavirus pandemic, patients across the U.S. have found themselves on the receiving end of unexpected bills ranging from hundreds of dollars to hundreds of thousands of dollars. A report released in September by the Kaiser Family Foundation, a nonprofit health news and research organization, estimated that the average cost for a COVID-related hospitalization was $20,000, with a mean out-of-pocket cost for insured individuals of $1,300.
For many Americans, that cost is untenable. Going into the pandemic, approximately 17.8% of people in the U.S. had medical debt that had gone into collections, according to an analysis published in the Journal of the American Medical Association in July. The average amount of those debts was $429.
This financial crisis isn’t over, and as hospitals and government groups begin to phase out economic assistance, it may only get worse.
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For patients who arrive at the emergency room with COVID symptoms, care varies widely depending on how sick they are, says Alison Haddock, MD, a Texas-based emergency physician and the vice president of the American College of Emergency Physicians’ Board of Directors.
“There are patients who are coming in who just aren’t that sick, and mostly need an examination and maybe some reassurance,” she said.
Those who are sicker, though, will likely need lab work, a chest X-ray and possibly a computerized tomography scan (CT scan) of the chest. From there, they may require medication such as remdesivir or monoclonal antibodies. The most serious cases require intubation and days- or weeks-long hospital stays.
The highest expense is the cost of a bed in the intensive care unit, says Haddock, although specific charges vary depending on the care a person receives.
“They require a great deal of staffing, including a very specialized physician and a nurse, potentially one who is dedicated to just your care,” she said. “The sicker you are, the more expensive the treatment is going to be.”
Early in the pandemic, many health insurance companies chose to waive patients’ out-of-pocket costs for COVID-19-related care. Under those programs, patients were not responsible for deductibles or copayments for in-network providers. Medicaid patients have few to no out-of-pocket costs associated with COVID-19-related care, and Medicare patients are subject to their standard deductibles and copayments. Hospitals also received billions of dollars in funding through the Coronavirus Aid, Relief, and Economic Security Act (CARES) and the Providers Relief Act, part of which went toward alleviating patient costs. But individuals who are uninsured are still vulnerable to high bills. And patients with insurance are as well, thanks to a practice known as surprise billing.
As its name suggests, surprise billing refers to a patient receiving a bill they didn’t expect. Most often, these bills are a result of a patient being unwittingly treated by an out-of-network provider — a doctor or specialist who works at a hospital but not for the hospital, and has not signed a contract with the patient’s health insurance provider.
This can happen easily in an emergency setting, where a patient may not have the capacity to understand who is treating them, and health care providers may not want to waste precious minutes — or hours — trying to figure out, or explain, the person’s insurance.
Gerald Kominski, a professor of health policy and management at the University of California, Los Angeles, says that surprise billing is less a model for medical care than a model for business.
“The whole idea of surprise billing is that people think that they’re going to [an in-network] hospital, for example, but the emergency room is carved out as being out-of-network,” he said. “There are companies that actually advise hospitals and emergency room doctors about the advantages of doing this. If [a provider is] out of network, then there is essentially no limit on what they can charge.”
For patients trying to make sense of surprise bills, the systems can be overwhelming. That’s no surprise, said Krutika Amin, an associate program director with the Kaiser Family Foundation.
“There are a lot of aspects that make it complicated,” she said. “It’s kind of a matrix of, like, were are you in a hospital that got [government] funds? What does your health plan do? That will affect how people are getting billed.”
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With vaccinations now widely available at no cost, some of the financial relief offered earlier in the pandemic will be phased out. According to a different Kaiser Family Foundation study, over 70 percent of the country’s largest insurers are no longer waiving out-of-pocket costs associated with COVID-19 treatment, and another 10 percent of plans are phasing out waivers by the end of October.
“Costs will go up,” said Caitlin Donovan, the senior director of public relations at the Washington, D.C.-based National Patient Advocate Foundation. “That’s the inevitable outcome.”
And when people are hit with bills they can’t afford and no relief in sight, “they declare bankruptcy,” said Kominski.
Another outcome will likely be that people with COVID-19 symptoms won’t go to the hospital, knowing that they likely can’t afford it.
“The worry becomes, again, that people with COVID are going to avoid the hospital,” said Donovan. “I am expecting to hear from more people worried about medical bills, and people worried about overall costs.”
There is some hope on the horizon. In January 2022, a new federal law will go into effect prohibiting emergency-care providers from sending surprise bills. Insurance companies will be required to work out charges for out-of-network providers rather than pass those costs on to patients, and patients will only be responsible for the costs they agreed to when they signed up for their plan.
In July of this year, the Biden administration announced that long COVID — which can lead to ongoing symptoms including joint and muscle pain, dizziness upon standing, and fatigue — could be considered a disability under the Americans with Disabilities Act. This would require businesses and other organizations to accommodate individuals with long COVID, and prevent them from being discriminated against.
The administration has also implemented more subsidies to help people buy health insurance, and opened enrollment for the Affordable Care Act year-round rather than just in the fall. But Kominski says it remains to be seen whether this will be enough.
“There has been a lot of effort,” he said. “But we’re going to need to monitor the consequences of COVID for a number of years moving forward, because it’s too fast-moving right now, and we don’t know what all the consequences are going to be, including the long term health consequences of people who’ve had COVID. We just don’t know what the magnitude of that is going to be.”
Donovan agrees.
“I’ve been with the National Patient Advocate Foundation for almost a decade, and I’ve never had that many people call me crying,” she said of calls she received at the onset of the pandemic. “So it’s worrying now that some of the insurers are no longer waiving those out-of-pocket expenses. Now we’re going to go back to the position of COVID being covered like anything else in the United States, which is to say, relatively poorly.”
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For Moreno and Gutiérrez, the resolution of their $83,385.10 bill was what Moreno calls a “miracle.” After getting the quote over the phone, she called the California Rural Legal Assistance, a law firm located in El Centro that has worked to assist individuals from the region apply for applicable financial relief programs. With a background in caregiving, Moreno was familiar with their work.
“We said, ‘We’re not gonna go crazy, we’re going to arrange whatever we can do,’” said Moreno. “We’re just gonna, you know, breathe in, breathe out, and figure something out.”
It took about a month, but eventually, the bill was paid under the federal government’s Health Resources and Services Administration’s Uninsured Program. Without the help, said Gutiérrez, they would have faced dire financial straits.
“I thank God,” said Moreno of the outcome. “I thank God. I’ve been blessed.”