The initial wave of vaccinations is underway, but let’s not forget that the COVID-19 pandemic has exacerbated the epidemic of precarious access to health care, an issue that the U.S. uniquely faces in the developed world. In 2018, a survey found that 44% would skip a doctor’s visit because they could not afford it. 33% reported delaying care for them or their families, with a staggering 25% having to do so for a serious medical condition. 29% reported not taking their medications as prescribed because of how expensive they are. Confronting the financial barriers to health care naturally has to be a centerpiece of any COVID-19 strategy due to the pandemic’s economic consequences, including the millions that have lost their health insurance through their employment.
President Joe Biden’s COVID-19 relief plan provides subsidies via a tax credit to buy coverage through the Affordable Care Act (ACA) marketplaces. It also lowers the percentage of people’s annual incomes that health insurances can collect through premiums, from 9.86% to 8.5%. Additionally, it subsidizes continuation coverage (COBRA) through September, allowing employees to keep their employer health insurance plans when unemployed.
However, this plan still leaves people exposed to financial barriers to health care in out-of-pocket costs (e.g., deductibles, co-pays, and coinsurance). In a recent study published in JAMA, patients with ACA plans on average had ten times the out-of-pocket costs compared to Medicaid. Although Biden’s plan addresses premiums, which averages several hundred dollars depending on both the tier of the insurance plan and the state one resides in, it does little about the deductible, which has doubled for the average individual since 2010. Subsidizing COBRA only pays for premiums, which does little for the many workers, often in the lower-income bracket, who have low premiums but high deductibles and copays. Although there are existing ACA cost-sharing subsidies, some plans have an average deductible of several thousands of dollars. It is more problematic if one barely does not qualify for financial assistance, which is the case for many people with fluctuating income in the COVID-19 world.
Even paying the deductible is not a guarantee that one’s health insurance will pay the expenses. Coverage purchased through the marketplace has an average in-network claims denial rate of 17.4%, with denial rates ranging from 1% to 57% of in-network claims. It is notably rare, only 0.2%, for people to appeal those claim denials to their insurers. Of those that do appeal, 60% uphold their original decision. In tandem with an ongoing pandemic and slow economy, this can exacerbate the uncertainty of a household’s finances.
Like many medical students across the country, I volunteer at free clinics where many patients rely upon prescription drug refills and other health-related needs. I listen emphatically about patients’ stories regarding the difficulties of obtaining health care in their conditions, a taxing endeavor on their mental and financial well-being. People are having to make a financial choice between paying their bills or health coverage.
Ordinary people are not the only ones affected by COVID-19. State governments have lost a ton of money because of the pandemic. Forty states reported declines in overall tax collection. My home state of Oklahoma is projected to have more than a $1 billion shortfall in the budget for the coming year as oil prices plummeted. It has to figure out how to fund Medicaid expansion, which was constitutionally mandated by popular vote this past summer. Because each state partially funds Medicaid, federal relief can be in the form of guaranteeing health coverage for the duration of the pandemic.
Such policy must directly address and balance these concerns. Fortunately, a policy does exist. The Health Care Emergency Guarantee Act (“the Act”), written by Senator Bernie Sanders and Representative Pramila Jayapal, has Medicare to cover medically necessary care and drugs for the uninsured. It also covers out-of-pocket costs, including deductibles and copays, for those with health insurance. It does this until the country is fully vaccinated, with some saying that this might not occur until 2022. To control spending, the Act allows Medicare to purchase pharmaceuticals at the same lower prices as the Veteran Health Administration and prohibits private insurances from increasing costs or decreasing coverage for the duration of the crisis.
Eliminating the out-of-pocket costs for patients would make a substantial difference in people’s lives during this unprecedented time. For someone that campaigned with the motto “Build Back Better,” it fits with expanding the already existing program for this endeavor. Will Biden’s administration leverage the political capital granted to them from a historic election to pursue such an avenue? It is wise for them to do so.
Daniel X. Pham is a medical student.
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