Loss of pandemic aid stresses hospitals
NASHVILLE, Tenn. — Mary Howard, a dishwasher with no health insurance, has never had COVID-19. But the coronavirus, she said, caused her life to spiral over the past two years.
Friends died from it. Ordinary parts of her day, like riding the bus, felt perilous. The restaurant where she worked closed temporarily, and she fought depression and high blood pressure, seeking care in the emergency room because inperson appointments were hard to come by as the pandemic raged.
She turned for help to Nashville General Hospital. The lone public safety-net hospital in a city with a booming health care industry, it has provided care to multitudes of poor and uninsured people throughout the pandemic and for more than 130 years.
Now, the end of federal programs that paid for COVID-19 care for the uninsured and helped stabilize hospital finances during the pandemic is threatening a new kind of crisis for people like Howard and the providers that care for them. Billions of dollars in aid not only guaranteed that uninsured COVID-19 patients would not face medical bills during the pandemic but also offered a lifeline for financially stressed institutions like Nashville General that provide extensive uncompensated care for the poor.
Slim margins
The infusion of aid is ending at a time when hospitalizations from COVID-19 are receding but as safety-net providers are facing tremendous unmet needs from patients who have delayed care for chronic conditions and other health problems even more than usual during the pandemic.
“Their margins are slim to begin with,” Beth Feldpush, senior vice president for policy and advocacy at America’s Essential Hospitals, which represents safety-net hospitals,
said of the institutions. She added that some were already having a “more difficult time bouncing back operationally and financially.”
Nashville General has seen an average of just one COVID-19 patient a week recently. But its doctors and nurses say that a wide range of health problems that worsened during the pandemic are now overwhelming the hospital.
Dr. Eric Neff, an orthopedic surgeon, said patients were afraid to visit the hospital during much of the pandemic and often had trouble finding transportation when they did. The consequences were dire: People waited six months to seek care for a broken wrist or ignored a torn rotator cuff, making it harder for him to fix their injuries.
Dr. Richard Fremont, a pulmonologist, said that he had treated dozens of COVID-19 patients over the past two years, but that patients with other health conditions, such as chronic asthma, had more often needed oxygen. Because uninsured patients cannot get shortterm home oxygen therapy, he sometimes keeps those who need it in the hospital for days or weeks.
The crisis of the uninsured is especially acute in Tennessee, which has one of the highest rates of hospital closures in the country and is among a dozen states that have chosen not to expand Medicaid to cover more low-income adults under the Affordable Care Act. Roughly 300,000 people in the state fall in the socalled coverage gap, meaning they are ineligible for either Medicaid or discounted health insurance under the Affordable Care Act despite having little to no income.
Pressure returns
John Graves, a health policy professor at Vanderbilt University School of Medicine, said the influx of relief funds during the pandemic had allowed something akin to a “universal coverage system within a system,” granting coverage to everyone who got COVID-19. Now, he said, hospitals and patients are back to facing pre-pandemic pressures — and will face even more once the federal government ends the public health emergency, which has temporarily increased Medicaid and Medicare reimbursements.
“The safety net has been disinvested in, and has been a political football, for a decade,” said Michele Johnson, executive director of the Tennessee Justice Center, a legal aid group that helps poor Tennesseans. The influx of pandemic aid, she added, “kind of covered up this thing that was barely hanging on the ropes; it put some rouge on the corpse.”