New story in Health from Time: COVID-19 Care Will Not End at Discharge—Government Help for the Uninsured Shouldn’t Either
Our patient had spent nearly a month on a ventilator, his lungs so diseased that every effort to allow him to breathe on his own had failed. And then, finally, he improved and the tube came out – he needed only oxygen from a mask. Now, he breathes without difficulty on his own.
But that is far from the whole story. Once off the ventilator, our patient – a previously healthy man in his 40s – was for a time unable to speak aside from occasional unintelligible sounds. Nor could he move his arms or legs. Happily, he has since recovered some of his ability to speak and move, but we still do not know how long-lasting his deficits will be.
What we are sure of is that he is not alone. While most COVID-19 sufferers never require hospitalization, those with the most severe form have to be put on ventilators to enable them to get sufficient oxygen. Even those in this group who are fortunate enough to survive their brush with the ventilator face a long road to recovery. Some will suffer permanent disability ranging from neurologic damage to kidney failure to post-traumatic stress disorder.
In March, the President announced that “hospitals and health care providers treating uninsured coronavirus patients will be reimbursed by the federal government.” This, he assured the nation, “should alleviate any concern uninsured Americans may have about seeking the coronavirus treatment.”
Unfortunately, it does not. Since this announcement, the federal government has shed little light on what the President’s promise covers. Nor has Congress specifically set aside funds for this purpose. And the specifics matter a great deal – they will mean the difference between families being able to care for their stricken loved ones and the prospect of financial ruin should they try.
Our national attention has been riveted on hospitals where we are now treating the sickest COVID-19 sufferers. But one of the biggest questions for those that survive will be whether government help will end with their discharge.
There is ample reason to suspect that a large number of survivors will require significant ongoing medical care once they leave the hospital. COVID is a complex disease affecting many of the body’s vital organs – some sufferers develop kidney failure, strokes, and heart damage, in addition to COVID’s better known respiratory symptoms.
Survival for some of these patients will require not just excellent hospital care but also intensive outpatient and home care, in addition to a panoply of medications and procedures. Stroke sufferers may need significant rehab or even nursing home care depending on the severity of their deficit. Patients with heart failure may need pacemakers or implantable defibrillators. Many survivors will need respiratory therapy, at least for a time, as their lungs struggle to heal from the viral onslaught.
This is on top of the symptoms we know afflict a high percentage of ICU patients regardless of their disease – notably ICU-acquired weakness due to prolonged immobilization, cognitive dysfunction, and post-traumatic stress disorder. Studies suggest at least a quarter of patients on a ventilator for longer than a week develop severe muscle weakness that can take months to resolve – in the meantime they may require significant support for even basic everyday activities such as dressing and feeding themselves. All the while, they will need rehab, and for many, mental health care as well.
Even in ordinary times, our patchwork health coverage system means millions of Americans face unimaginable choices between paying for rent and food or paying for life-saving medical care. Tragically, that number will inevitably swell at precisely the time when being uninsured can have profound consequences.
Because most Americans receive insurance through their employer, losing a job will for many mean losing their health coverage, too. A recent study by the Urban Institute and the Robert Wood Johnson Foundation estimated that seven million Americans previously covered through their jobs would lose health coverage entirely due to unemployment resulting from this pandemic. The only reason the number is not higher is because some of the newly unemployed will be able to obtain coverage through Medicaid or the Affordable Care Act (ACA).
Without health insurance, few Americans can hope to afford the high cost care needed to recover from a prolonged ICU stay under even the best medical circumstances, let alone if there is more permanent damage to their kidneys, brains, or lungs.
If the Administration and Congress are serious about taking care of those stricken by this pandemic and ensuring that their road to recovery does not bankrupt them, they must make this commitment both clear and concrete. And journalists should demand specifics about what will be covered and what will not be.
While our patient remains in the hospital, an extraordinary constellation of expertise is being martialed to his aid. Nutrition experts carefully titrate his diet. Speech pathologists help us determine what he can eat while minimizing the risk of aspirating food. Physical therapists try to help him regain the use of his limbs.
A number of New York hospitals have been marking clinical milestones on the road to recovery. One of the hospitals where I work has started playing a song over the loudspeaker to note the stable discharge of a COVID patient – recently, it has been “Here Comes the Sun” by the Beatles or the theme from the movie Rocky.
In this time of fear and suffering – the scratchy sound of these notes over the hospital public announcement system represents a rare ray of hope. It is a much-needed reminder to all the hospital staff who have risked their own lives that that sacrifice has not been in vain. Our patients have fought their way through unimaginable suffering – we cannot now abandon them the moment they get their discharge papers. Otherwise, those hopeful chords will ring hollow indeed.