At the start of the pandemic, many wished there was a pill people could swallow to make a COVID-19 infection go away. Two years later, we have not just one, but two of these pills, in addition to other outpatient and inpatient treatments.
The federal government has established programs in 2020 to ensure access to COVID care regardless of insurance status. But studies show that life-saving treatments have not been equally accessible to all who need them. Among people who tested positive for COVID-19, patients of color were less likely to access monoclonal antibody treatments, analysis findsfrom the United States Centers for Disease Control and Prevention.
In mid-March, Congress rejected calls from the White House to funnel more money into programs aimed at breaking down barriers to COVID care and helping the most vulnerable. This means that COVID tests and treatments will no longer be guaranteed free for uninsured people. Public health experts expect the situation to worsen disparities in access to treatment and other COVID-related care, as does another subvariant could soon cause a new wave of cases.
“We have a history in the United States of pumping a lot of money into public health during an emergency and then scaling back once the emergency is over,” said Jeffrey Levi, professor of politics and management at health at George Washington University. “I think what we’re seeing now is for the first time, Congress is actually downsizing in the middle of an emergency, which is even worse.”
The “boom and bust cycle,” he said, makes it almost impossible to sustainably improve health equity. And it is the most vulnerable in the country who are suffering.
For example, the federal government will end the program put in place in May 2020 to reimburse suppliers to test and vaccinate people against COVID. Now those who are uninsured or underinsured could be charged for vaccines and COVID tests.
“What I see playing out is: uninsured people avoiding COVID-related care. For low-income people, even relatively low co-payments will inevitably deter people from getting tested,” said Dr. Adam Gaffney, a primary care physician in pulmonary and critical care and a professor at Harvard Medical School.
This could hamper infection control and worsen COVID data and surveillance efforts. More importantly, Gaffney said, it will prevent the nation’s most vulnerable from accessing effective treatments, like oral antiviral pills and monoclonal antibodies. Some of these drugs have been shown to reduce the risk of hospitalization or death in high-risk patients by up to 89%. But to get any of these treatments, you need a positive COVID test and a prescription.
“We’re starting to treat COVID more like any other disease: care is rationed by the ability to pay,” he said. “And that’s the exact opposite of what we should be doing.”
A system that ‘favors the rich’ could become even more inequitable
Even with the federal dollars flowing, the uninsured were more likely to be infected with the coronavirus and less likely to get tested for that. They were also less likely to get vaccinated, even though the vaccines were free.
But that does not mean that the programs were not used. According to Gaffney’s analysis of CDC data, the program covered nearly $19 billion in services, including $6 billion in treatment, $1.6 billion in vaccines and $11 billion in COVID testing for people. uninsured.
All of that will go away if federal lawmakers don’t take action to restore funding.
Funding cuts mean COVID treatments, which are already in short supply, will become even scarcer.
The federal government purchased millions of doses of four outpatient COVID treatments. Most of the supply is being distributed through state health departments to hospitals, pharmacies and clinics requesting doses. A portion has been reserved for direct shipment to clinics who operate in underserved communities disproportionately affected by COVID-19.
The White House has said the supply could run out as early as the end of May if funding is cut.
When supplies are scarce, designing equitable distribution systems becomes even more important to ensure fairness, said Dr Douglas White, Endowed Chair in Ethics in Critical Care Medicine at the University of Pittsburgh Medical Center.
But many states have not done so, he said, opting for a “first come, first served” system.
“We know that ‘first come, first served’ favors the wealthy and the well-connected,” White said. “And for people who have limited access to health care, ‘first come, first served’ essentially puts them at the end of the line.”
About 9% of the U.S. population is uninsured, and black and Hispanic Americans are more likely to be uninsured compared to white Americans, according to data from the U.S. Census Bureau.
States don’t track who gets COVID treatments
Most states have no information about who is receiving outpatient COVID treatment because they don’t ask for it.
After setting aside 15 percent of therapeutics for health centers that cater to underserved populations, the federal government has left it up to each state to decide how to distribute the remaining 85%.
Health officials in many states have directed supplies to large hospital systems and commercial pharmacies, where anyone with a prescription can receive them.
But other states, like Minnesota, have tried a different approach. The state is restricting distribution of the oral antiviral Paxlovid to healthcare facilities where a system is in place to prioritize patients who need it most.
JP Leider, director of the Center for Public Health Systems at the University of Minnesota School of Public Health, helped develop Minnesota’s allocation system. He said the approach allows high-demand drugs to be reserved in low quantities for patients most at risk, easing that burden from places like commercial pharmacies.
The federal government provided guidance on who was clinically eligible for treatments, but that still left some discretion to the states.
During the omicron wave, for example, Leider said there were up to 10 clinically eligible patients waiting per dose of monoclonal antibody treatment in Minnesota. Most states have experienced similar scenarios of extreme shortages.
The federal government also does not require providers to track or report demographic information about people who receive the treatments. So many Midwestern states, including Ohio, Indiana, and Illinois, don’t require it either.
This concerns Dr. Giselle Corbie, director of the Center for Health Equity Research at the University of North Carolina Chapel Hill.
“The reality is that this data is critically important,” she said. “Health inequalities disappear when we stop collecting data on race and other social identities, but the impact remains.”
Corbie worries that disparities in access to health care will be exacerbated as programs to promote equity in access to COVID care come to an end.
Beth Rwoble, CEO of HealthLinc, a federally licensed community health center in Indiana, shares those concerns. For now, she said the center still has “lots” of tests, vaccines and treatments to serve the uninsured, but funding cuts will create further challenges for her clinic.
“We are so used to having to find ways to serve our uninsured. It’s just another hurdle that we have to find a way to overcome,” Rwoble said. “My wish is that we have more heads held high.”
People can’t access treatment they don’t know exists
Even though the supply of COVID therapies has been limited, Rwoble said demand has been lower than she expected.
Until recently, HealthLinc in Valparaiso, Indiana was the only federally qualified health center in the state to receive drop-shipments new COVID antiviral drugs. Rwoble said the clinic received 245 doses in January. But by mid-March only 60 doses – less than a quarter of the supply – had been used.
Federal data shows millions of doses also sit unused on pharmacy shelves nationwide, according to NPR reports.
Rwoble said she wondered if people weren’t getting as sick as they were at the start of the pandemic and therefore didn’t seek COVID treatment.
Low demand may also be due to a lack of awareness of treatments and knowledge of how to obtain them.
The White House has launched a new website, COVID.gov, which aims to make it easier to find COVID treatments, tests and vaccines.
But even if people know about the treatments, that doesn’t guarantee fair distribution. Dr. William Trick, director of the Collaborative and Hospitalist Research Unit at Cook County Health in Illinois, said racial minorities and underserved populations are those who likely need treatment the most but are the least likely to access it.
Trick co-authored a CDC study which found relatively equal access to hospital treatment once patients were sick enough to be hospitalized. But for outpatient treatments, like monoclonal antibodies, researchers found from November 2020 to August 2021, Hispanic patients received treatment 58% less often than non-Hispanic patients, and black and Asian patients received treatment 22 % and 48% less often, respectively, than white patients.
Part of the reason could be that people of color are more likely to face barriers, such as the inability to miss work when sick and reduced access to primary care physicians. As a result, black and Hispanic patients may not seek treatment until they are seriously ill and need hospitalization.
“The problem isn’t just distribution,” Trick said. “How is it to educate people about the drug and get to the right clinical setting to get the drug?
This story comes from a reporting collaboration that includes Indianapolis Recorder and Side Effects Public Media – a public health information initiative based at WFYI. Follow Farah on Twitter: @Farah_Yousrym.