Jamie Azar left a rehab hospital in Tennessee this week with the help of a walker after spending the entire month of August in the ICU and on a ventilator. She had received a shot of the Johnson & Johnson vaccine in mid-July but tested positive for the coronavirus within 11 days and nearly died.
Now Azar, who earns about $36,000 a year as the director of a preschool at a Baptist church in Georgia, is facing thousands of dollars in medical expenses that she can't afford.
"I'm very thankful to be home. I am still weak. And I'm just waiting for the bills to come in to know what to do with them," she said Wednesday, after returning home.
In 2020, as the pandemic took hold, U.S. health insurance companies declared they would cover 100 percent of the costs for COVID treatment, waiving co-pays and expensive deductibles for hospital stays that frequently range into the hundreds of thousands of dollars.
But this year, most insurers have reinstated co-pays and deductibles for COVID patients, in many cases even before vaccines became widely available. The companies imposed the costs as industry profits remained strong or grew in 2020, with insurers paying out less to cover elective procedures that hospitals suspended during the crisis.
Now the financial burden of COVID is falling unevenly on patients across the country, varying widely by health-care plan and geography, according to a survey of the two largest health plans in every state by the nonprofit and nonpartisan Kaiser Family Foundation.
If you're fortunate enough to live in Vermont or New Mexico, for instance, state mandates require insurance companies to cover 100 percent of treatment. But most Americans with COVID are now exposed to the uncertainty, confusion and expense of business-as-usual medical billing and insurance practices — joining those with cancer, diabetes and other serious, costly illnesses.
A widow with no children, Azar, 57, is part of the unlucky majority. Her experience is a sign of what to expect if COVID, as most scientists fear, becomes endemic: a permanent, regular health threat.
The carrier for her employee health insurance, UnitedHealthcare, reinstated patient cost-sharing Jan. 31. That means, because she got sick months later, she could be on the hook for $5,500 in deductibles, co-pays and out-of-network charges this year for her care in a Georgia hospital near her home, including her ICU stay, according to estimates by her family. They anticipate she could face another $5,500 in uncovered expenses next year as her recovery continues.
Bills related to her stay at the out-of-network rehab hospital in Tennessee could climb as high as $10,000 more, her relatives have estimated, but they acknowledged they were uncertain this month what exactly to expect, even after asking UnitedHealthcare and the providers.
"We still don't know where the numbers will land because the system makes the family wait for the bills," said Azar's sister, Rebecca Straub.
UnitedHealthcare declined to comment specifically about Azar's situation unless she signed a blanket waiver allowing release of all her health records — which she declined.
In general, a person with Azar's type of plan would have an in-network deductible of $1,500 and an in-network out-of-pocket maximum of $4,000, said UnitedHealthcare spokeswoman Tracey Lempner in an e-mail. Lempner declined to say what a patient's out-of-network, out-of-state share would be at the Tennessee rehab hospital.
She did not respond directly to a question about why UnitedHealthcare chose Jan. 31 to stop waiving deductibles and co-pays for COVID treatment.
"The cost-share waivers were just one piece of our overall response to the covid-19 pandemic," Lempner said. "We have focused our efforts around helping our members get access to covid-19-related tests, vaccines and treatment, while providing additional support to our clients, care providers and local communities." UnitedHealthGroup, UnitedHealthcare's parent company, reported $15.4 billion in profits in 2020, up from $13.8 billion in 2019.
The charges Azar anticipates would be budget-crushers, Straub said. Her relatives are seeking help from the public on a nonprofit patient-fundraising website called Help Hope Live, which says it verifies the circumstances of each patient's condition with medical providers.
In a Facebook video call from her hospital bed in Chattanooga last week, Azar cited prayer from family and friends for helping her maintain a positive attitude. Although she considers the change in insurance practices unjust for people who get sick this year, she said she harbors no personal animosity toward UnitedHealthcare.
"I got here a year late, huh?" she quipped. "Even though it may not seem fair or seem right, it's where we are."
She said her doctors surmised she may have already been exposed to the coronavirus when she received her Johnson & Johnson shot in July.
The lack of uniformity in COVID insurance practices across the country this year is striking. In some places, because of differences in health plan policies, COVID patients in the same hospitals and in the same ICU units could be facing completely different financial burdens.
"There was no federal mandate for insurers to cover all the costs for COVID treatment. Insurers were doing it voluntarily," said Krutika Amin, a Kaiser Family Foundation associate director who researchers health insurance practices.
Last year, according to the Kaiser Family Foundation, 88 percent of people covered by private insurance had their co-pays and deductibles for covid treatment waived. By August 2021, only 28 percent of the two largest plans in each state and D.C. still had the waivers in place, and another 10 percent planned to phase them out by the end of October, the Kaiser survey found. Its survey this year of employer-sponsored plans reflected similar patterns.
"For some people, deductibles can be over $8,000 for a hospital stay," Amin said. "It will really depend on what plan they have."
America's Health Insurance Plans, the industry's lobbying and trade group, said insurance companies began to reinstate cost-sharing for COVID treatment as vaccines became available and in recognition that the coronavirus will be an ongoing health challenge.
"After a year and a half, it's pretty clear that COVID is here to stay, that this is a continuing health condition," AHIP spokesman David Allen said. "When it comes to treatment, we're looking at it like we would treat any other health condition."
The industry says it is not using the return of deductibles as financial incentive for people to get vaccines. To encourage vaccinations, the industry is focused on "carrots, not sticks," Allen said, with programs targeting education and making sure no one is billed for receiving vaccines.
In Painesville, Ohio, Becky Calderone, a hairdresser and graphic artist, has been contending with a steady stream of bills and collection notices for seven months, she said, after she and her husband were both stricken with COVID in February. Her husband was hospitalized; she was not. Anthem Blue Cross and Blue Shield, which was provided through her spouse's employer, reimposed patient cost-sharing for COVID treatment Jan. 31.
Calderone and her husband did not fit the criteria for early vaccine supplies, which were targeted in January and February toward the elderly. The couple did not get vaccinated until May, well after they got sick.
"We were stuck in this gap," Calderone said. Thirty days after her husband's release from the hospital, she said, "the bills started coming in like a flood."
Calderone described navigating a bureaucratic odyssey of e-mails and appeals with Anthem as well as contact with state insurance regulators. Now she is receiving letters "up the wazoo" from collections agencies. Anthem agreed to waive her husband's deductibles, she said, but the bills from various providers are still inexplicably arriving. Her deductibles remain in place, she said, but she has not been told why.
Calderone said the financial hardships may mount even further. The couple has a new insurance company now, because her husband changed jobs, so they will have to meet another set of deductibles and co-pays this year as they battle long-hauler COVID symptoms, including irregular heartbeats and chronic fatigue, she said.
Anthem did not respond to requests for comment specifically about Calderone's claims. A spokesman said Calderone would need to sign a waiver to release medical information. Calderone declined.
In a general statement, the company said its waivers last year were one of a number of steps it took to help its members manage the impacts of the virus.
"These waivers ended in January as we all had gained a better understanding of the virus, and people and communities became more familiar with best practices and protocols for limiting COVID-19 exposure and spread," the company said in a statement. "Also, at this time vaccines, which are proven to be the safest and most effective way to protect oneself from COVID-19, were starting to become readily available."
Anthem took in $4.6 billion in profits in 2020, compared to $4.8 billion in 2019.
The reintroduction of cost-sharing mainly affects people with private or employer-based insurance. Patients with no insurance can have 100 percent of their expenses covered by the federal government, under a special program set up by the government for the pandemic, with hospitals reimbursed for care at Medicare rates.
COVID patients with Medicaid, the government plan for lower-income people that is paid for by states and the federal government, continue to be protected from cost-sharing, insurance specialists said. Patients on Medicare, the federal plan for the elderly, could face out-of-pocket costs if they do not have supplemental insurance.
For large commercial plans, the pandemic created an unusual dynamic in 2020. Hospitals stopped performing elective procedures, because of the risk of infection and because they were overwhelmed in many communities, so insurance companies had to pay out fewer claims.
"Insurers may have also wanted to be sympathetic toward pains patients, and some may have also feared the possibility of a federal mandate to provide care free-of-charge to COVID-19 patients, so they voluntarily waived these costs for at least some period of time during the pandemic," the Kaiser Family Foundation report said.
Nationally, COVID hospitalizations under insurance contracts on average cost $29,000, or $156,000 for a patient with oxygen levels so low that they require a ventilator and ICU treatment, according to data gathered by the national independent nonprofit FAIR Health.
"Insurers wanted to encourage people to get treatment. And this was something that, almost more than any illnesses and health conditions, was something that you have no control over,'' said Jack Hoadley, research professor emeritus at the Georgetown University Center on Health Insurance Reforms. "The insurers probably had a sense that there was a moral obligation to not put patients on the spot for this kind of thing."
Insurance companies participating in Affordable Care Act marketplaces also faced the prospect of having to pay rebates to the government if their profit ratios exceeded certain levels.
The calculus in place in 2020 changed with the advent of vaccines, which now makes most hospitalizations preventable, Hoadley said.
In some cases, the patchwork of policies and plans is creating stark differences in circumstances for individual patients in the same facility.
Hospitals along the Connecticut River, the border between Vermont and New Hampshire, draw patients from both states. Vermont health plans are waiving deductibles and co-pays into 2022. In New Hampshire, where Anthem Blue Cross Blue Shield has a dominant presence, insurance companies have reinstated cost-sharing.
Marvin Mallek, a doctor who treats COVID patients from both sides of the river at Springfield Hospital in Vermont, said New Hampshire COVID patients are now facing business as usual from insurers, suffering the same sort of financial stress that routinely affects patients with cancer, heart disease and other serious ailments.
"The inhumanity of our health-care system and the tragedies it creates will now resume and will now cover this one group that was exempted,'' he said. "The U.S. health-care system is sort of like a game of musical chairs where there are not enough chairs, and some people are going to get hurt and devastated financially."
Hospitals also are in the position of having to resume billings and collections for individuals who may have been laid off because of the pandemic or been too sick to work, experts said.
"If you ever wanted a study in differential treatment, this is it," said Ray Berry, chief executive officer of his own company, Health Business Solutions, in Cooper City, Fla., and a member of the North Broward Hospital board. "You can have people in beds right next to each other, and one can pay $3,000 and one can pay nothing. … The folks who do pay it are going to get sticker shock."