COVID-19 Reveals the Dark Side of US Health Care Coverage
By Shannon Rotolo, PharmD, BCPS
Within the first three to four months of the COVID-19 pandemic, an estimated 186,000 workers in Illinois and their families lost their health insurance coverage due to job losses. Nationwide estimates in June 2020 suggest as many as 7.7 million workers and 6.9 million of their dependents lost employer-sponsored insurance (ESI) when they lost their jobs during the pandemic-induced recession. And while Illinois has more state-run programs and support available than many other states, many individuals and families losing coverage do not qualify for Medicaid, and many can’t afford other so-called low-cost plans. Even those who are able to obtain alternate health insurance may be left with gaps in their coverage. We know from pre-pandemic data that having a gap in coverage more than doubles the likelihood that someone will forego filling a prescription. Additionally, for individuals or families that have not lost their ESI, but for whom a meaningful portion of their household income was variable – for example restaurant servers, bartenders, hair stylists, or nail technicians who earnings may be dramatically impacted by tips – the same ESI plan that was previously sufficient may now leave them underinsured. The definition of underinsurance varies somewhat between studies, but generally this refers to an insured person or family facing out-of-pocket costs (ex. premiums, deductibles, and / or copayments) at such a high proportion of total household income that health care is not affordable, or is only able to be procured at the expense of other basic necessities.
Pharmacists have been observing the impact of this health insurance crisis from the front lines. Other health care professionals may not know the reason why a patient cancels an appointment or delays care. It could be cost, fear of COVID-19, a scheduling conflict, difficulty securing transportation, or one of so many other variables or barriers. But pharmacists, and in particular community pharmacists, often talk to patients who are struggling with tough decisions between a basket of groceries and a prescription refill. The pandemic has increased the frequency of these interactions in a country that was already leading our peer nations in numbers of uninsured and underinsured residents. And people make these difficult decisions between medications and other necessities monthly. Perhaps an annual screening or well check-up can be defered without major issues in some situations, but delaying a prescription refill has a clear, visible consequence: running out of medication. And while missing only a few days of a medication for high blood pressure, for example, may not directly and immediately lead to a stroke for everyone, there are certain medications that do have serious, predictable consequences. A person with Type I diabetes can develop life-threatening complications within hours to days of running out of insulin.
Earlier in the pandemic, roughly May to June, I remember a scramble as many of the patients I worked with at the specialty pharmacy were no longer able to afford their high-cost medications. The pharmacy technicians and I were frantically filling out patient assistance program applications or grant fund applications to try and obtain medication for patients via limited free drug programs offered by drug manufacturers or charitable organizations whose funds were vanishing as quickly as they could be repleted by donors. I struggled to answer questions with no good answers for my patients: What should I do if the monthly cost of COBRA coverage for my family is the same as our total budget for the month, that is meant to include groceries and gas to get to the few shifts of work that are still available? Should I consider getting legally divorced so either my spouse or I might qualify for health coverage based on our individual income? What happens if I miss a week of this medication, if I know I have nothing in my debit account today, but I’m expecting a deposit on the 1st or the 15th of the next month? What will happen to me?
While the economic impacts of the COVID-19 pandemic have been felt globally, the idea of losing health insurance and prescription drug coverage as a consequence of this pandemic-induced economic downturn is almost uniquely American. Other high-income countries have single-payer systems that guarantee health care as a human right to their citizens. People there may be fearful of contracting COVID-19, but not because the cost of care will bankrupt them, as it could here in the United States.
We know controlling the spread of the virus will be crucial to getting our economy back on track. We should also consider the impact of our health care system on our ability to fight this virus. Now is the time to tell our elected representatives that we demand at a minimum universal coverage of a COVID-19 vaccine, and also universal health care coverage, period. It has never been more important to protect each other.
Dr. Shannon Rotolo, PharmD, BCPS is a clinical pharmacy specialist at the University of Chicago Medicine. She also serves as IMPACT’s Pharmacy Advisor.