Access to healthcare in childhood has long term effects on health outcomes, but many children in the US are either uninsured or underinsured, meaning they often don’t have access to the care they need. Why is that and what can we do about it?
President Biden promised on the campaign trail to expand the Affordable Care Act to cover more of the roughly 29 million nonelderly Americans (about 11 percent of that population) who remain uninsured. He also said he’d strengthen the law by, for instance, providing an accessible and affordable public option and increasing tax credits to make it easier for people who buy insurance on their own to afford monthly premiums. Once in office, Biden immediately moved to reopen the period when people could enroll in the ACA marketplaces.
Unfortunately, the administration is paying little heed to a problem that is in many ways just as insidious as lack of insurance: underinsurance. That’s when people get too little from the insurance plans that they do have.
After passage of the ACA, the number of Americans lacking any insurance fell by 20 million, dropping to 26.7 million in 2016 — a historic low as a percentage of population. The figure began to creep up again during the Trump administration, reaching 28.9 million in 2019. That’s the problem that the current administration wants to address, and it certainly needs attention.
But according to research by the Commonwealth Fund, a foundation focused on health care, 21.3 percent of Americans have insurance so skimpy that they count as underinsured: Their out-of-pocket health-care expenses, excluding premiums, amount to at least 5 to 10 percent of household income. The limits in coverage mean their plans might provide little financial protection in a health-care crisis.
High-deductible plans offered by employers are one part of the problem. Among people covered by the companies they work for, enrollment in high-deductible health plans rose from 4 percent in 2006 to 30 percent in 2019, according to a report from the Kaiser Family Foundation. The average annual deductibles in such plans are $2,583 for an individual and $5,335 for families.
In theory, high-deductible plans, which make people spend lots of their own money before insurance kicks in, turn people into careful consumers. But research finds that people covered by such plans skip care, both unnecessary (elective cosmetic surgery, for instance) and necessary (cancer screenings and treatment, and prescriptions). Black Americans in these plans disproportionately avoid treatment, widening racial health inequities.
Health savings accounts are designed to blunt the harmful effects of high-deductible plans: Contributions by employers, and pretax contributions by individuals, help to cover costs until the deductible is reached. But not all high-deductible health plans offer such accounts, and many people in lower-wage jobs don’t have them. In the rare cases that they do, they often don’t have extra money to deposit in them.
In a November 2020 article in the journal Health Affairs, scholars affiliated with Brown University and Boston University found that enrollment in high-deductible plans had increased across all racial, ethnic and income groups from 2007 to 2018; they also found that low-income, Black and Hispanic enrollees were significantly less likely than other groups to have a health savings account — and the disparities had grown over time.
The short-term health-care plans — a.k.a. “junk” plans — that the Trump administration expanded also contribute to the problem of underinsurance. They often have low premiums but do not cover preexisting conditions or basic services like emergency health care.
Fortunately, proposals like Biden’s that make health care more accessible also tend to address the problem of underinsurance, at least in part. For example, to make individual-market insurance more affordable, Biden proposes expanding the tax credits established under the ACA. His plan calls for removing the cap on financial assistance, now set at 400 percent of the federal poverty level, in the insurance marketplaces and lowering the statutory limit on premiums to 8.5 percent of income (from nearly 10 percent).
The president also proposes to peg the size of the tax credits that subsidize premiums to the best plans on the marketplaces, the “gold” plans, rather than “silver” plans. This would increase the size of these credits, thereby making it easier for Americans to afford more-generous plans with lower deductibles.
The most ambitious Biden proposal is a public option, which would create a Medicare-like offering on marketplaces, available to anyone. Pairing this with allowing any American to opt out of their employer plan if they found a better deal on HealthCare.gov or their state marketplace — which they can’t now — would help some people escape high-deductible plans. The public option would also eliminate premiums and involve minimal to no cost-sharing for low-income enrollees — especially helpful for uninsured (and underinsured) people in states yet to expand Medicaid.
Given political realities, however, this policy may not see the light of day. So it would be best to target underinsurance directly. Most people with high-deductible plans get them through an employer. Yet unlike in the marketplace plans, the degree of cost sharing in these employer plans is the same for low-income as well as high-income employees. To deal with that problem, the government could offer incentives for employers to expand the scope of health services they cover — even in high-deductible plans. Already, many such plans exempt from the deductible some primary-care visits and generic-drug prescriptions. The list could grow to include follow-up visits and certain specialist care.
Instead of encouraging health savings accounts, the government could offer greater pretax incentives that encourage employers to absorb some of the costs that they have shifted onto their lower-income employees; that would help to prevent the insurance equity gap from widening further. The government could compensate employers that cover co-pays or other costs for their low-income employees. It could also subsidize employers that move away from high-deductible plans, at least for lower-income people.
Health insurance is complicated: More-affordable premiums are good only if they don’t bring stingy coverage. Greater investment in well-trained (and racially diverse) “navigators” — the people who help Americans enroll in plans on the federal marketplace, for example — would make it less likely that consumers would choose high-deductible plans without grasping their downsides. But it’s also important that people have options beyond risky high-deductible coverage.
The ACA expanded coverage dramatically — but the government needs to make sure that coverage amounts to more than an unused insurance card.
Thursday was healthcare day at the Biden White House, the latest in a series of themed days during which the President has issued executive orders on topics ranging from COVID response to climate change to racial equity.
Facing a closely divided Congress, the new administration has focused so far on actions it can take unilaterally to advance its agenda, and as President Biden described it at a signing ceremony yesterday, his healthcare agenda is centered on “restoring the Affordable Care Act and restoring Medicaid to the way it was” prior to the Trump administration.
The new executive order reopens the HealthCare.gov insurance marketplace for a “special enrollment period”, lasting from mid-February to mid-May, allowing approximately 15M uninsured Americans in 36 states (including 3M who lost employer-based insurance due to COVID) to sign up for coverage, many subsidized by the federal government.
The order also instructs agencies to review many of the regulatory changes made by the Trump administration, including loosening restrictions on short-term insurance plans, and allowing states to use waivers to implement Medicaid work requirements. (Also included in Thursday’s action was a measure to immediately rescind the ban on taxpayer funding for abortion-related counseling by international nonprofits, the so-called “Mexico City rule”.)
Actually unwinding those Trump-era changes will take months (or possibly years) of regulatory work to accomplish, but Biden’s executive order puts that work in motion. Attention now turns to Congress, which the Biden team hopes will provide funding for increased subsidies for coverage on the Obamacare exchanges, along with allocating money for the administration’s aggressive COVID response plan.
Yesterday’s executive order is best understood as the starting gun for the lengthy legislative and regulatory process that lies ahead, as the Biden administration tries to bolster the 2010 health reform law, and stamp its mark on American healthcare.
The nearest-term 2021 actions will likely center on bolstering the ACA and Medicaid, after the Trump administration took aim at both.
Even with Democrats’ surprise flipping of the Senate, enacting big healthcare policies in Congress will be a heavy lift given the razor-thin margin in that body and division within the party on strategy.
A clearer path for incoming president Joe Biden is to focus on reversing policies enacted by President Donald Trump at the executive level. Trump’s tenure has been defined in large part by a chipping away at key tenets of the Affordable Care Act, curtailing the Medicaid program and sweeping deregulations critics allege harm consumer protections.
The nearest-term actions the incoming administration is likely to take will center on bolstering the landmark health law and Medicaid, both of which has drawn more bipartisan backing in recent years. Below are what the Biden health administration is likely to roll back quickly after inauguration Wednesday.
Boosting Affordable Care Act marketplace
One of Biden’s first moves may be to open a special enrollment period to sign up for coverage during COVID-19, combined with more outreach and enrollment assistance, Cynthia Cox, director of the ACA program at the Kaiser Family Foundation, said.
Beyond COVID-19, it’s likely the Biden administration will restore federal spending on navigation, marketing and outreach for exchange plans. For example, the Trump administration reduced the minimum number of navigator programs in each state using the federal marketplace to one. Biden could return it to two, and might also bring back the requirement that navigators have a physical presence in their service area.
Biden is also likely to unilaterally shore up standards for brokers, and take steps to bolster the exchange website healthcare.gov.
The Trump administration in December proposed a rule encouraging states to privatize their health insurance marketplaces instead of using healthcare.gov, which will make it more difficult for consumers to shop between plans and could divert people to subpar coverage, Tara Straw, senior policy analyst at the Center on Budget and Policy Priorities, wrote in a December blog post.
The rule doubles down on the administration’s approval of a Georgia waiver to privatize its marketplace in November, but would allow states to follow suit and rely entirely on third-party brokers without a waiver.
That rule is not yet final, so Biden’s HHS will likely remove it from the Federal Register to avoid fragmenting marketplace functions.
Biden could also beef up consumer protections and standards for web brokers, which also sell skimpy short-term health insurance and other non-ACA-compliant coverage.
Biden is also likely to re-expand the annual enrollment period. In 2017, the Trump administration shortened the annual enrollment period to 45 days. Biden’s HHS could use rulemaking to return that period to three full months.
The incoming administration could also reverse previous CMS guidance on Section 1332 waivers that let states subvert or sidestep ACA protections on coverage and cost. The Trump administration proposed a rule in November to codify the waiver standards in regulation but — despite a recent wave of proposed and final regulations as the Trump administration hustles to preserve its health agenda — the rule has not yet been finalized, so HHS could remove it from the Federal Register as well.
By nixing the rule, Biden could also help reverse Trump administration cuts from 2018 that slashed user fees on healthcare.gov plans. The November proposed rule would further decimate the fees, which finance a large swath of marketplace operating expenses, to 2.25% in 2022, versus 3% in 2021 and 3.5% last year.
One key tenet of Biden’s health agenda is to expand ACA subsidies to more low-income Americans, something he can’t do without Congress. However, Biden could use administrative processes to reverse a Trump-era method for indexing marketplace subsidies that kicked in for the 2020 plan year, which led to a small reduction in the financial aid.
Dialing back short-term and association health plans
Biden’s HHS could also roll back the controversial expansion of short-term health plans, bare-bones coverage that isn’t required to cover the 10 essential health benefits under the ACA.
Short-term plans were created as inexpensive stop-gap insurance that could last for up to three months, giving consumers peace of mind while they shopped more comprehensive coverage. However, in 2018, the Trump administration expanded the duration of the plans to 12 months, with a three-year renewal period, and also allowed all consumers — not just those who couldn’t afford other options — to purchase them.
HHS touted the expansion as giving consumers more options, while noting they weren’t meant for everyone. A yearlong investigation by House Democrats found the plans widely discriminate against women and people with pre-existing conditions, and had major coverage limitations leaving unwitting consumers susceptible to surprise medical bills.
The Biden administration could enact stricter limits against the sale of the plans. Through additional rulemaking, HHS could limit future enrollment or make it harder to renew short-term coverage, enact stronger consumer protections or beef up standards to limit their sale.
Though actions around limiting new people coming into the plans are likely, Biden may wait to see if Congress takes up the issue, experts say.
A growing number of Americans in the individual healthcare market have subscribed the inexpensive coverage amid skyrocketing medical costs. Roughly 3 million consumers bought the plans in 2019, a 27% growth from 2018, the investigation found. The explosive growth in use makes it a bit less likely Biden’s HHS would pursue immediate, unilateral movement in the space, for fear of kicking Americans off their coverage.
Biden could also reverse Trump’s regulatory changes that have been friendly to association health plans, which allow small businesses or groups to band together to offer coverage. Though the ACA enhanced oversight of the coverage, the Trump administration in June 2018 issued a rule exempting them from rules regulating individual and small-group employer coverage.
As a result, association health plans were allowed to exclude or charge more on the basis of gender, age or other factors.
A federal court invalidated the rule later that year, and some states took legislative or regulatory actions to discourage the use of association health plans. However, the plans —which cover an estimated 3 million Americans — are still not required to cover all essential health benefits, making them a likely target for the Biden administration.
“It is something that we’re going to see some action on pretty soon, but it’s challenging. You don’t want to take those plans away from people, especially during a pandemic,” Cox said.
Expanding Medicaid coverage, eligibility
The Trump administration has given red states new avenues to constrict their Medicaid programs, which provide safety-net health insurance to some 75 million Americans.
Biden will likely first revise state demonstration waiver policies to expand coverage. Among other measures, Biden could get rid of past CMS guidance allowing states to play with Medicaid eligibility through work requirements, controversial programs tying coverage eligibility to work or volunteering hours, and to cap program funding.
Tennessee this month became the first state to receive a federal green light to convert its Medicaid funding to a block grant, following controversial CMS guidance issued early last year. Republicans tout block grants as a way to lower costs, while Democrats oppose the models as capped funding could lead to restricted benefits down the line, especially during times of emergency like a pandemic or natural disaster.
It’s more difficult to roll back a waiver if it’s already been approved, but Biden could put restrictions on it or reverse the decision before it goes into effect, experts say, though Tennessee would have an opportunity to object.
There are also actions Biden could take to reinstate certain beneficiary protections, which would require regulatory changes, KFF researchers say. Those include revising or stopping pending proposals that would change how Medicaid eligibility is determined in a way that would probably result in previously eligible people losing coverage by enacting more documentation requirements; change the government’s methodology for recouping improper payments; and reduce enhanced federal funding for eligibility workers.
Biden’s administration could also tweak regulations that have already been finalized, including the final Medicaid managed care rule for 2020 that relaxed network adequacy, beneficiary protections and quality oversight.
In swing states from Georgia to Arizona, the Affordable Care Act — and concerns over protecting preexisting conditions — loom over key races for Congress and the presidency.
“I can’t even believe it’s in jeopardy,” says Noshin Rafieei, a 36-year-old from Phoenix. “The people that are trying to eliminate the protection for individuals such as myself with preexisting conditions, they must not understand what it’s like.”
In 2016, Rafieei was diagnosed with colon cancer. A year later, her doctor discovered it had spread to her liver.
“I was taking oral chemo, morning and night — just imagine that’s your breakfast, essentially, and your dinner,” Rafieei says.
In February, she underwent a liver transplant.
Rafieei does have health insurance now through her employer, but she fears whether her medical history could disqualify her from getting care in the future.
“I had to pray that my insurance would approve of my transplant just in the nick of time,” she says. “I had that Stage 4 label attached to my name and that has dollar signs. Who wants to invest in someone with Stage 4?”
“That is no way to feel,” she adds.
After doing her research, Rafieei says she intends to vote for Joe Biden, who helped get the ACA passed in this first place.
“Health care for me is just the driving factor,” she says.
Even 10 years after the Affordable Care Act locked in a health care protection that Americans now overwhelmingly support — guarantees that insurers cannot deny coverage or charge more based on preexisting medical conditions — voters once again face contradicting campaign promises over which candidate will preserve the law’s legacy.
A majority of Democrats, independents and Republicans say they want their new president to preserve the ACA’s provision that protects as many as 135 million people from potentially being unable to get health care because of their medical history.
President Trump has pledged to keep this in place, even as his administration heads to the U.S Supreme Court the week after Election Day to argue the entire law should be struck down.
“We’ll always protect people with preexisting,” Trump said in the most recent debate. “I’d like to terminate Obamacare, come up with a brand new, beautiful health care.”
And yet the Trump administration has not unveiled a health care plan or identified any specific components it might include. In 2017, the administration joined with congressional Republicans to dismantle the Affordable Care Act, but none of the GOP-backed replacement plans could summon enough votes. The Republicans’ final attempt, a limited “skinny repeal” of parts of the ACA, failed in the Senate because of resistance within their own party.
In an attempt to reassure wary voters, Trump recently signed an executive order that asserts protections for preexisting conditions will stay in place, but legal experts say this has no teeth.
“It’s basically a pinky promise, but it doesn’t have teeth,” says Swapna Reddy, a clinical assistant professor at Arizona State University’s College of Health Solutions. “What is the enforceability? The order really doesn’t have any effect because it can’t regulate the insurance industry.”
Since the 2017 repeal and replace efforts, the health care law has continued to gain popularity.
Public approval is now at an all-time high, but polling shows many Republicans still don’t view the ACA as synonymous with its most popular provision — protections for preexisting conditions.
Democrats hope to change that.
“If you have a preexisting condition — heart disease, diabetes, breast cancer — they are coming for you,” said Biden’s running mate, California Sen. Kamala Harris, during her recent debate with Vice President Pence.
Voters support maintaining ACA’s legal protections
In key swing states, many voters say protecting preexisting conditions is their top health concern.
Rafieei, the Phoenix woman with colon cancer, still often has problems getting her treatments covered. Her insurance has denied medications that help quell the painful side effects of chemotherapy or complications related to her transplant.
“During those chemo days, I’d think, wow, I’m really sick, and I just got off the phone with my pharmacy and they’re denying me something that could possibly help me,” she says.
Because of her transplant, she will be on medication for the rest of her life, and sometimes she even has nightmares about being away and running out of it.
“I will have these panic attacks like, ‘Where’s my medicine? Oh my god, I have to get back to get my medicine?'”
Election season and talk of eliminating the ACA has not given Rafieei much reassurance, though.
“I cannot stomach politics. I am beyond terrified,” she says.
And yet she plans to head to the polls — in person — despite having a compromised immune system.
“It might be a long day. But you know what? I want to fix whatever I can,” she says.
A few days after she votes, she’ll get a coronavirus test and go in for another round of surgery.
A key health issue in political swing states
Rafieei’s home state of Arizona is emblematic of the political contradictions around the health care law.
The Republican-led state reaped the benefits of the ACA. Arizona’s uninsured rate dropped considerably since 2010, in part because it expanded Medicaid.
But the state’s governor also embraced the Republican effort to repeal and replace the law in 2017, and now Arizona’s attorney general is part of the lawsuit that will be heard by the Supreme Court on Nov. 10 that could topple the entire law.
Depending on how the Supreme Court rules, ASU’s Reddy says any meaningful replacement for preexisting conditions would involve Congress and the next president.
“At the moment, we have absolutely no national replacement plan,” she says.
Meanwhile, some states have passed their own laws to maintain protections for preexisting conditions, in the event the ACA is struck down. But Reddy says those vary considerably from state to state.
For example, Arizona’s law, passed just earlier this year, only prevents insurers from outright denying coverage — consumers with preexisting conditions can be charged more.
“We are in this season of chaos around the Affordable Care Act,” says Reddy. “From a consumer perspective, it’s really hard to decipher all these details.”
As in the congressional midterm election of 2018, Democrats are hammering away at Republican’s track record on preexisting conditions and the ACA.
In Arizona, Mark Kelly, the Democratic candidate running for Senate, has run ads and used every opportunity to remind voters of Republican Sen. Martha McSally’s votes to repeal the law.
In Georgia, Democratic challenger Jon Ossoff has taken a similar approach.
“Can you look down the camera and tell the people of this state why you voted four times to allow insurance companies to deny us health care coverage because we may suffer from diabetes or heart disease or have cancer in remission?” Ossoff said during a debate with his opponent, Republican Sen. David Purdue.
Republicans have often tried to skirt health care as a major issue this election cycle because there isn’t the same political advantage to pushing the repeal and replace argument, says Mark Peterson, a professor of public policy, political science and law at UCLA.
“It’s political suicide, there doesn’t seem to be any real political advantage anymore,” says Peterson.
But the timing of the Supreme Court case — exactly a week after election day — has somewhat obscured the issue for voters.
Republicans have chipped away at the health care law by reducing the individual mandate — the provision requiring consumers to purchase insurance — to zero dollars.
The premise of the Supreme Court case is that the ACA no longer qualifies as a tax because of this change in the penalty.
“It is an extraordinary stretch, even among many conservative legal scholars, to say that the entire law is predicated on the existence of an enforced individual mandate,” says Peterson.
The court could rule in a very limited way that does not disrupt the entire law or protections for preexisting conditions, he says.
Like many issues this election, Peterson says there is a big disconnect between what voters in the two parties believe is at stake with the ACA.
“Not everybody, particularly Republicans, associates the ACA with protecting preexisting conditions,” he says. “But it is pretty striking that overwhelmingly Democrats and Independents do — and a number of Republicans — that’s enough to give a significant national supermajority.”
President Trump vowed to overhaul the health care system, notably saying in one of his first post-election speeches that pharmaceutical companies were “getting away with murder” over their pricing tactics.
Yes, but: Four years later, not a lot has changed. If anything, the health care industry has become more financially and politically powerful, Axios’ Bob Herman reports.
“Most of the bigger ideas have either been stopped in the courts or just never got implemented,” said Cynthia Cox, a vice president at the Kaiser Family Foundation who follows the health care industry.
- The administration killed its own regulation that would have changed behind-the-scenes negotiations between drug companies and pharmacy benefit managers.
- One of the most consequential drug proposals — tying Medicare drug prices to lower prices negotiated abroad — is not remotely close to going into effect.
- Forcing drug companies to disclose prices in TV ads was a small gambit, and the courts ultimately struck down the idea.
The other side: The policies the administration has seen through, so far, have been relatively modest.
- New rules could force hospitals and health insurers to disclose their secret prices. Hospitals have sued, although the courts are not sympathetic to their pleas, and health insurers still have two years before their rule could go into effect.
- A federal appeals court upheld Trump’s cuts related to a federal drug discount program for hospitals and hospital-based clinic payments, but the industry is considering taking the cases to the Supreme Court.
- Trump made it easier to sell short-term health plans.
Less than three months from now, either Donald Trump will begin his second term as President, or Joe Biden will begin his first. What the U.S. healthcare system on that date and moving forward could be starkly different depending on who is sworn in.
The policy differences between the two men are essentially on opposite poles. If fully enacted, Trump’s policies could potentially cause tens of millions of Americans to lose their healthcare coverage. Biden’s policies would likely provide healthcare access to tens of millions more Americans compared to today.
In November, the U.S. Supreme Court will hear arguments in a case called California v. Texas. It stems from the 2017 tax bill that zeroed out the penalty individuals paid if they did not obtain health insurance. The argument put forth by the 20 Republican state attorney generals in that case is if the individual mandate no longer has taxing power, the entire law should be declared unconstitutional based upon a lack of severability of the entire law.
Many legal scholars have noted that this case is premised on a shaky argument. But with a 6-3 majority of conservative justices now on the high court, many bets are off as to the ACA’s survival. And President Trump just said in an interview with “60 Minutes” he fervently hoped the ACA is eliminated. He put forth no alternatives to the ACA in that interview.
Should the ACA be declared unconstitutional, health insurance for some 23 million people would be imperiled. That includes some 12 million Americans who are eligible for Medicaid under the ACA’s expanded income guidelines, and another 11 million who purchase insurance on the state and federal health insurance exchanges – roughly 85% of whom receive premium subsidies that make it more affordable. Moreover, another 14 million Americans who are estimated to have lost their employer-based health plans during the COVID-19 pandemic may not have another place to turn for coverage.
Before the ACA case, the Trump administration also promoted so-called “off-exchange” health plans, and health sharing ministries. The first is often a form of short-term health insurance, the second operates as a cooperative serving those of the same religious stripe. Both offer health coverage that is potentially cheaper that what is offered on the exchanges, but both also tend to cap it at low dollar levels. Many also bar applicants for a variety of claims, such as for maternity or cancer care, or if they have pre-existing medical conditions – practices prohibited for ACA plans.
Should Trump be re-elected and the ACA survives constitutional muster, expect to see many states apply for more waivers from that law. Georgia just received approval to modestly expand Medicaid eligibility, primarily for those poor already working 80 hours or more a month. The state is also on the cusp of being able to opt out of the healthcare.gov exchange entirely and have consumers work directly with insurance brokers to purchase coverage. However, there is nothing in the pending waiver to prevent those brokers from offering stripped-down coverage without the ACA protections that the Trump administration is already promoting.
There could also be more block grants to states for their Medicaid budgets, which most experts have concluded would reduce the number of enrollees in that program.
If Biden is elected and both incoming houses of Congress are also Democratic, the entire Supreme Court case can be mooted simply by reattaching a financial penalty to the individual mandate. That hasn’t been mentioned at all during the campaign, presumably because Biden does not want to discuss what would essentially be a promise to raise taxes. But it is the most direct way to skirt the risk of an adverse Supreme Court decision.
Biden’s campaign has also put forth numerous proposals to enlarge the ACA and the Medicare program. They include expanded premium subsidies for individuals and families to purchase coverage, and a public health plan option – which would allow those who live in the states that have yet to expand Medicaid to obtain coverage. Biden has also proposed a buy-in to Medicare at age 60.
The estimates are that an expanded ACA and other Biden plans could net another 20 to 25 million Americans healthcare coverage. That would leave fewer than 10 million – 2% to 3% of the population – without access to coverage. It would probably be as close to universal healthcare as the United States could get given its current political realities.
The two different approaches will either lead to a country where virtually everyone has access to healthcare coverage and services, or one where 50 million or more people could potentially be uninsured. It’s a shift that could impact a minimum of 45 million people – and that’s not even counting those who lost their coverage during the current public health crisis.
Elections have consequences. Less than three months from now, this one will determine whether the U.S. healthcare system will take one consequential path over another.
President Donald Trump spent three days in the hospital. He arrived and left by helicopter. And he received multiple coronavirus tests, oxygen, steroids and an experimental antibody treatment.
For someone who isn’t president, that would cost more than $100,000 in the American health system. Patients could face significant surprise bills and medical debt even after health insurance paid its share.
The biggest financial risks would come not from the hospital stay but from the services provided elsewhere, including helicopter transit and repeated coronavirus testing.
Trump has praised the high quality of care he received at Walter Reed National Military Medical Center, and has played down the risk of the virus. “Don’t be afraid of Covid,” Trump tweeted on Monday, before returning to the White House. “Don’t let it dominate your life.”
Across the country, patients have struggled with both the long-term health and financial effects of contracting coronavirus. Nearly half a million have been hospitalized. Routine tests can result in thousands of dollars in uncovered charges; hospitalized patients have received bills upward of $400,000.
Trump did not have to worry about the costs of his care, which are covered by the federal government. Most Americans, including many who carry health coverage, do worry about receiving medical care they cannot afford.
For some Americans, the bills could start mounting with frequent tests. Insurers are generally required to pay for those tests when physicians order them, but not when employers do.
The Trump administration made that clear in June, when it issued guidance stating that insurers do not have to pay for “testing conducted to screen for general workplace health and safety.” Instead, patients need to pay for that type of testing themselves. Some might be able to get free tests at public sites, and some employers may voluntarily cover the costs. Others could face significant medical debt from tests delivered at hospitals or urgent care centers.
COVID tests can be expensive. Although they typically cost $100, one emergency room in Texas has charged as much as $6,408 for a drive-through test. About 2.4% of coronavirus tests billed to insurers leave the patient responsible for some portion of payment, according to the health data firm Castlight. With 108 million tests performed in the United States, that could amount to millions of tests that leave patients responsible for some share of the cost.
Marta Bartan, who works as a hair colorist in New York City, needed a coronavirus test to return to her job this summer. She received a $1,394 bill from the hospital running the drive-through site where she was tested.
“I was so confused,” said Bartan, who is contesting the bill. “You go in to get a COVID test expecting it to be free. What could they have possibly charged me $1,400 for?”
The bills for the typical American would continue at the hospital, with the routine monitoring that any patient would receive and the drugs provided in the course of care.
Remdesivir, a new coronavirus treatment created by Gilead, costs $3,120 when purchased by private insurers and $2,340 with public programs like Medicare and Medicaid.
Trump also received an experimental antibody treatment from Regeneron. It’s currently available to clinical trial participants or to those granted a “compassionate use” exemption. In either situation, the drug would typically be provided to the patient at no charge. This will most likely change, however, when the treatment finishes trials and hits the commercial market. These types of drugs are hard to manufacture, and other monoclonal antibodies cost thousands of dollars.
Health economists are only starting to understand the full costs of coronavirus treatment, just as scientists are mapping out how the disease works and spreads. They do have some early estimates: The median charge for a coronavirus hospitalization for a patient over 60 is $61,912, according to a claims database, FAIR Health
That figure includes any medical care during the hospital stay, such as an emergency room visit that led to admission or drugs provided by the hospital.
For insured patients, that price would typically be negotiated lower by their health plan. FAIR Health estimates that the median amount paid is $31,575. That amount, like most things in American health care, varies significantly from one patient to another.
In the FAIR Health data on coronavirus patients over 60, one-quarter face charges less than $26,821 for their hospital stay. Another quarter face charges higher than $193,149, in part because of longer stays.
Many, but not all, health insurers have said they will not apply copayments or deductibles to patients’ coronavirus hospital stays, which could help shield patients from large bills.
Uninsured patients, however, could be stuck with the entire hospital charges and not receive any discounts. While the Trump administration did set up a fund to cover coronavirus testing and treatment costs for the uninsured, The New York Times has reported that some Americans without health insurance have received large bills for their hospital stays.
The biggest billing risk for a patient receiving treatment similar to Trump’s would probably come from helicopter rides to the hospital.
Air ambulances are expensive and often not in major health insurance plans’ networks. The median charge for an air ambulance is $38,770, according to a study in the journal Health Affairs published this year. When the helicopter trip is out of network — as about three-quarters of them are — patients are left with a median charge of $21,698 after the insurance payout.
Taking two helicopter rides, as Trump did, could plausibly result in more than $40,000 in medical debt for patients without access to their own aircraft (though of course most people do not leave the hospital by helicopter).
The financial consequences of a coronavirus hospitalization could be long-lasting, if a new Supreme Court challenge to the Affordable Care Act is successful. That case argues that all of Obamacare is unconstitutional, including the health law’s protections for preexisting conditions. The administration filed a brief in June supporting the challenge.
The Supreme Court hears that case on Nov. 10. If the challenge succeeds, COVID-19 could join a long list of preexisting conditions that would leave patients facing higher premiums or denials of coverage. In that case, coronavirus survivors could face a future in which their hospital stays increase their health costs for years to come.
This article originally appeared in The New York Times.