As America reels amid the coronavirus outbreak, our nation’s infamous uninsurance (and underinsurance) crisis takes center stage with special insistence. The unaffordability of health care, and the scant financial protection that characterizes the U.S. health system, should trouble us not just for humanitarian reasons but because it severely hampers our ability to respond to a public health crisis and curb the epidemic that may already enjoy a running start due to the Trump administration’s botched testing rollout. We’ve already heard stories like those of Frank Wucinski and Osmel Martinez Azcue, who both ultimately tested negative for COVID-19 but were still hit by $3,000 to $4,000 hospital bills.*
Some have suggested we simply cover the cost of the coronavirus test, associated therapy to treat it, or even imposed quarantine. Those measures are imperative, but they will not be enough on their own, especially when the COVID-19 symptoms of concern overlap with so many other conditions. Consider what happens if someone short of breath delays seeking care and testing for fear of the medical bills they will incur if it turns out to be something like asthma, leaving them holding the bill for the visit and services. Those individuals, some portion of whom do have the virus, will stay out of the health system longer and, in the interim, transmit the virus more widely than they would if their condition received timely identification and intervention. If more Americans contract the disease from exposure to unknown carriers, more people will suffer and more will die than if we had a strong system of coverage in place to encourage rather than deter people from seeking needed medical care broadly. In other words, to stop the coronavirus, we need to treat people who don’t have the coronavirus.
Infectious disease is the textbook illustration of how the privileged cannot wall themselves off from others’ misfortune: The virus sees the biological human community that we try to deny, and ultimately those harmed will include not just those who lack insurance but anyone in the pathway of transmission. Each of us has a stake in everyone else’s prompt access to health services and that is why we should quickly deploy a tool that has proved effective in other emergencies: presumptive Medicaid eligibility for all who seek care, even if they ultimately do not test positive for the coronavirus. People won’t enter the health care system for screening if they think other aspects of the visit will saddle them with medical debt. By contrast, financial assurance of proper treatment for whatever their condition entails does bring people in and thereby enable earlier, more comprehensive intervention to curtail the spread of disease.
There’s a precedent for this. Almost 19 years ago, when planes struck the World Trade Center on Sept. 11, I was working as a health staffer for then-Sen. Hillary Clinton of New York. Thousands of New Yorkers suddenly needed screening and immediate medical attention, but many had no health insurance. Disaster Relief Medicaid (DRM) filled the gap. The application for coverage was simplified to just one page. It could be filled out at the point of care, and eligibility was decided on the spot. The eligibility had been relaxed so that more people qualified, and applicants could self-attest to information such as income, since the computer system for processing documentation and eligibility had been damaged in the attacks. Once enrolled, a person’s DRM coverage lasted four months, after which, participants could transition to regular Medicaid if they met ordinary rules.
Word traveled quickly, assuring affected New Yorkers that they could access care at an otherwise uncertain time. Uptake exceeded expectations and many recipients reported that they were able to see a doctor immediately after enrolling, although even more could have been done to streamline those paths. Since then, we’ve used similar Medicaid expansions in our response to hurricanes, the H1N1 swine flu epidemic, and the lead contamination in Flint. These flexibilities have been used to temporarily suspend cost-sharing, add new services, and authorize alternative care settings. Congress has, in some cases, provided 100 percent federal funding rather than the split between state and federal financing associated with regular Medicaid.
The Trump administration has fumbled the initial coronavirus response package, lowballing the funds requested, raising alarms that a vaccine, once developed, may not be affordable to all, and still failing even with a supplemental appropriations package in hand to clarify whether they will use potential emergency authorities to reimburse hospitals, much less other categories of providers. Other administration proposals floated include tax cuts and restrictions on travel from Mexico, which run aslant to the real imperatives to control the pandemic. Meanwhile the administration’s recently released budget dusts off the tired proposal to block-grant Medicaid, which seems particularly inapt at this juncture. Such a change would undermine the precise feature of Medicaid, the open-ended financing structure, that enables it to respond so quickly to unexpected health threats. Any serious response package should include this basic Medicaid extension for all Americans at risk of COVID-19. Health emergencies make visible and urgent what Americans fighting for universal health coverage have known all long: When it comes to our lives and our flourishing, we are all in it together.
Correction, March 6, 2020: Due to a photo provider error, the caption for the photo misidentified Nancy Pelosi as the House majority leader. She is the House speaker. The piece also originally misspelled Osmel Martinez Azcue’s first name.