The thought of coming down with COVID-19, the disease referred to in everyday conversation simply as “coronavirus,” is enough to put a real scare into Terryl Banta, a 30-year-old restaurant manager in Washington state. Surviving a potentially fatal respiratory illness sounds hard enough, but for Banta, who has no health insurance, that’s just the beginning of the nightmare.
“If I actually had to go the doctor,” she told The Daily Beast, “it would absolutely drain my savings and change everything. I wouldn’t be able to get married this fall, wouldn’t be able to contribute to a down payment on a house, and I’d probably have to sell my car and cash out my 401k from a previous job.”
COVID-19, also called the 2019 novel coronavirus, is still an evolving problem. On Thursday, the San Francisco Chronicle reported that at least 22 more evacuees from the Diamond Princess cruise ship off the coast of Japan were believed to be infected, in addition to 14 U.S. cases already linked to that voyage. At least 15 other Americans had previously been confirmed as infected with the illness by the Centers for Disease Control and Prevention (CDC).
At the same time, another, less novel public health problem was simmering in the background: the number of Americans without health insurance has gone up in each of the past two years surveyed by the Kaiser Family Foundation. By the nonprofit health research outfit’s count, 27.9 million people lacked insurance in 2018.
According to Matthew K. Wynia, a doctor and the director of the University of Colorado’s Center for Bioethics and Humanities, anxiety about incurring massive expenses is exactly what we don’t want while we have a potential pandemic hanging over us. “In the context of a public health emergency, you want everyone to be able to access the healthcare system,” he said. “You don’t want people with a contagious illness deciding, I’m too afraid.”
And as attorney Lawrence Gostin, author of the controversial Model State Emergency Health Powers Act—which would expand the power of states to quarantine infected people against their will—notes, the risks uninsured people cause aren’t borne exclusively by them. Indeed, the reality of tens of millions of people without health insurance and an outbreak federal officials expect to get worse before it gets better points to a uniquely American potential for disaster.
“Lack of health insurance could result in a person delaying seeing a doctor or being turned away,” Gostin, a Georgetown professor and expert on public health law, told me in an email. “That just fuels an epidemic.”
There hasn’t yet been a sufficiently dire domestic disease outbreak to know exactly what the fallout of uninsured Americans during a pandemic would be. But the risks are fairly obvious, even to the uninsured themselves. “Most of my friends my age don’t [have health insurance] save for those who have been in more stable jobs than restaurants for a while,” Banta said. “Most of my friends are in the industry and are thus similarly not wealthy.”
Another uninsured service worker, Lesley Almaraz, a 27-year-old bartender in Texas, said more or less the same thing: “I very seldom encounter co-workers that have health insurance.”
According to Allison Aiello, professor of epidemiology at the University of North Carolina at Chapel Hill, these anecdotal concerns touch on the concept of “assortativity”—a type of clumping of individuals with similar traits. When assortativity affects a viral outbreak, Aiello explained, “if you’re in that group of individuals that is affected by an infection, it’s going to move more quickly through that group because you interact with those individuals more.” (Still, she cautioned, there isn’t sufficient data out there to definitively link the concept to people without health insurance spreading an illness more quickly.)
Compounding this potential problem, according to Wynia, is the phenomenon of “presenteeism,” or going to work when you shouldn’t. Service sector workers typically get few sick days, if any, and miss out on tips if they drop a shift, which is a big concern for epidemiologists every flu season, and an even bigger concern when there’s an outbreak. “There have been infectious disease outbreaks among workers in bars and so on in the past—not of COVID-19, but of other things like tuberculosis. So we've worried about that for a long time,” Wynia said.
As for what awaits the uninsured if they do go to the doctor with novel coronavirus, the good news is that they most likely won’t be turned away. “If you present with an emergency condition, pursuant to what’s known as EMTALA, which is a federal act that requires them to screen them and treat you at that juncture, you’re going to get that care,” said James Hodge, director of the Center for Public Health Law at Arizona State University. “There will be an attempt, I can almost assure, to provide every level of care possible without charge to persons who simply can’t afford it.”
But that’s about where the good news ends. In a strange twist, uninsured patients who find themselves in quarantine, as opposed to isolation, are the lucky ones. Generally, a quarantine is a government operation, and in theory, none of the 346 Americans who were released this week from coronavirus quarantine by the CDC had to pay for any medical care they received there. “CDC under its own regulations has to pay for all of that, unless they could bill a private insurance or other carrier for such expenses,” Hodge explained. “If you can’t [pay], you’re still getting the same services that everybody else would get in a quarantine scenario.”
But generally, quarantine is for patients who were exposed, but aren’t showing symptoms. If an uninsured patient shows up at a hospital with COVID-19, and receives a diagnosis, they most likely won’t be quarantined, and will instead be placed in a hospital isolation unit, where the traditional—and arguably dystopian—American billing apparatus will be in full effect.
While most COVID cases aren’t debilitating, Hodge explained that for the roughly 20 percent who do need to be hospitalized, “expenses could rack up pretty quickly.” And for those unlucky enough to become mortally ill, if they’re uninsured, they’ll also have to deal with “a lot of additional care that could get catastrophically expensive.”
Currently, the disease is still mostly concentrated in its hot zone, China’s Hubei province—in a country that boasts universal health care (though that might not be entirely accurate). But until the disease is contained, the worst-case scenario of COVID-19 outbreaks within pockets of the uninsured in the U.S. looms.
“If it spreads in the United States, there will be a lot of Americans in that situation,” Hodge said.
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