In mid-March, American comedian Baten Phillips, also known as Baldhead Phillips, had an itch in his throat and a flight to catch.
When his plane landed in Atlanta where he lives, he was drenched in sweat, felt dizzy and had trouble breathing. His wife took him to the nearest emergency room.
The public hospital diagnosed him with strep throat and sent him home, but he returned two days later and tested positive for COVID-19. He fought for his life in the intensive care unit for six weeks, at which point the hospital gave him a choice: stay longer and add to his bill, or leave and pay for oxygen at a lower cost.
Phillips has diabetes, making his COVID-19 infection more severe, and with no health insurance, he pays for medication and hospital costs out-of-pocket. He chose to leave.
So far, Phillips has $14,000 in medical bills. His hospital received $145m through the CARES Act that was supposed to provide aid to hospitals hit hard by COVID-19, but the hospital told Al Jazeera the aid did not cover its entire financial gap.
“The cost of medical care is ridiculous, especially for an illness like this,” said Phillips, who started a GoFundMe to cover the cost.
“People are going into more debt just to fight this.”
While Phillips said he is grateful for the care he received, he urged the United States to take some pointers from countries with universal healthcare – a system that public health experts and physicians say saves lives during a pandemic.
For example, the COVID-19 death rate in Canada, which has a single-payer healthcare system, is less than half that of the US, where a profit-driven, private-public model often allows people to fall through the cracks.
While COVID-19 arrived in the neighbouring countries around the same time in late January, as of November 10, Canada had 282 deaths per million residents while the US had 722 deaths per million people.
A universal healthcare system “makes a big difference in a lot of ways”, said Dr Danielle Martin, a Canadian doctor who testified before a US Senate committee investigating healthcare.
Free testing, treatment
Lives are mostly saved in a pandemic through political and public health decision-making, Martin explained.
That includes imposing travel restrictions, encouraging mask use and physical distancing, conducting testing and contact-tracing, closing non-essential services, providing basic income so people can stay home, and taking decisive action at all levels of government.
“But when people get sick with COVID-19 there is no doubt that access to high-quality healthcare – testing and treatment – can save their lives, and therefore having universal access to it is a critical component of a comprehensive pandemic response,” Martin told Al Jazeera.
Canada has a publicly-funded system delivered by the provinces. Under the Canada Health Act, everyone is entitled to receive medically-necessary services without copays. Under this system, Canada provides free COVID-19 treatment and testing.
By comparison, the cost of hospital treatment and testing for COVID-19 in the US can vary widely, with one COVID-19 survivor being billed $1.1m by a hospital in Seattle – a sum that was later covered by Medicare.
The Kaiser Family Foundation, a healthcare research non-profit, found that US testing facilities charged $20 to $850 per test. In many cases, the costs exceeded Medicare coverage for testing, which ranges from $51 to $100.
When people get sick with COVID-19 there is no doubt that access to high-quality healthcare - testing and treatment - can save their lives
Martin said if a person knows he does not have to pay out-of-pocket for a hospital stay or testing, he is more likely to declare his symptoms and ask for help, or stay longer in hospital and follow through on the care he needs, giving him a better health outcome.
That is taking on a new urgency today, as the US recorded its highest daily infection rate on November 13, adding about 153,500 new cases to its tally of nearly 10.6 million infections, according to Johns Hopkins University data.
On November 10, the US surpassed its record for COVID-19 hospitalisations, as well, AP news agency reported.
In Canada, COVID-19 deaths have mostly been in long-term care homes; while medically-necessary physician and hospital services are covered by Canada’s Health Act, personal support and nursing in these homes are not, so residents provide copayment.
Underlying health conditions
COVID-19 health outcomes are also worse for people with underlying conditions who have no health insurance because no insurance means they have to pay out-of-pocket for the medications and doctor visits they need, so many go without.
Nearly 33 million Americans below 65 are uninsured, according to the latest estimate from the Centers for Disease Control and Prevention (CDC).
Michigan critical care doctor Ahmer Rehman said he saw this dichotomy among insured and uninsured diabetes patients who also tested positive for COVID-19. “Those uninsured people have uncontrolled diabetes, so their COVID symptoms were much worse, and they died much quicker,” he told Al Jazeera.
Rehman said in his experience, the US system pressures hospitals to discharge patients quickly because insurance companies give hospitals money for a set number of days based on the initial diagnosis.
The administrators of the hospital where he works encourage physicians to discharge patients sooner so the hospital can turn a profit, he said, although the company will not pay the hospital if the patient returns with complications.
He said his hospital ranks physicians on the number of days their patients stay, and posts their ranking on a bulletin board in the doctors’ lounge – putting pressure on doctors with a poor ranking.
“You just feel the stress to get them out quicker. It does cloud your judgement a little bit.”
Public vs private hospitals
Phillips, who is Black, said the virus “spread like wildfire” through his community in Atlanta.
African Americans had the highest COVID-19 death rate of any racial group in the US, according to the CDC, and the death rate for Black Americans was 2.1 times higher than for white Americans.
Universal healthcare might have improved Phillips’s outcome, Rehman said: “With subsidised diabetes medication and regular doctor visits, his body might have been more resilient against COVID-19 and free and accessible testing might have given him a faster diagnosis.
Phillips also said he likely would have stayed in the hospital longer if he knew he did not have to pay for it.
In New York City, which has the highest death rate in the US, the virus hit low-income, racialised communities the hardest. Patients from these communities mostly ended up in public hospitals, according to The New York Times, which reported that patients in public hospitals were three times more likely to die compared with those at private hospitals.
Public hospitals in the city also struggled to transfer patients to private hospitals, which would have eased the pressure. Rehman said if a patient does not have insurance, a private hospital might reject a request to take on a patient because the hospital is worried it may not get paid. “It’s a coin flip in a lot of situations, for private hospitals,” he said.
COVID-19 also hit racialised communities in Canada the hardest.
“In the Canadian context, it’s easier to smooth that out because those hospitals are expected to collaborate with each other,” said Martin, who added that since all Canadian hospitals are paid by the government, transfers happen without question.
“That also allows hospitals to smooth out the high degree of variability between neighbourhoods that occur due to social factors including systemic racism.”