Andrew Cencini got off relatively easy. Like many early COVID-19 patients in the United States, the upstate New York native and computer science professor at Vermont’s Bennington College struggled to shake a flu-like illness in late February and early March 2020, seeking treatment only after it dawned that he could be infected amid news of rising COVID-19 caseloads. He’d spent much of February in New York City, an early hot spot.
According to Kaiser Health News, Cencini got tested for the flu and other non-COVID-19 illnesses at his doctor’s office on March 5. The results came back negative. Four days later, as his symptoms persisted, he called his doctor again. This time, he was directed to a local hospital emergency department to get chest X-rays and be tested for COVID-19, the illness caused by the novel coronavirus now known as SARS-CoV-2.
A brief stay in an isolation ward followed.
Days later, Cencini was fine: back at work, albeit remotely, and symptom-free. But he wasn’t out of the woods. His insurance company determined he would be on the hook for about $2,000 in hospital expenses — the first of what could be many bills related to his mild illness. While Cencini’s test was free under the first major piece of coronavirus stimulus legislation passed by Congress, his brief hospitalization wasn’t. IVs, X-rays, beds — they all cost money, and lots of it, even for patients with health insurance. Had Cencini known what he was in for, he wouldn’t have bothered to get tested.
But Cencini was comparatively fortunate. Patients with more severe illness face medical bills many multiples higher than his. Writing for the BMJ, Jessica Wapner tells the story of Susan Adair, an Oklahoma woman whose husband died after 16 days in a COVID-19 hospital ward in April 2020. Adair’s insurance company billed her for nearly $30,000 in costs related to her husband’s treatment in the weeks following his death, with additional bills expected. A recovered Virginia woman interviewed by Wapner received bills totaling $150,000 from her insurance company after a severe spring bout of COVID-19. “I think I’m going to have to sell my house in order to pay these medical bills,” she said.
These patients’ stories are not unique. They’ve been repeated countless times in the months since. And such stories are even more harrowing for patients without private health insurance or government-sponsored coverage. Cencini, Adair, and Wapner could all count on their insurers covering the majority of their in-network treatment costs — roughly 60% to 90% for typical Affordable Care Act (ACA)-compliant plans. Eye-popping as they already are, their financial burdens would likely be much higher without insurance.
With the pandemic showing no signs of abating, millions more Americans will face crushing COVID-19 treatment bills before all is said and done. Even if you can’t control how the disease affects you, informed health care consumers owe it to themselves to know what to expect financially after a turn for the worse.
Factors Influencing Coronavirus Treatment & Severity
COVID-19 severity occurs along a gradient influenced by many different factors.
Two factors not directly related to patient health also influence disease severity: patient age and initial viral load (the amount of virus you’re exposed to). Older patients and those with greater exposure — which is likelier for those who don’t follow CDC guidelines to maintain social distance, wear masks, and wash their hands — have a higher risk of more severe disease.
- Age. Age is starkly correlated with COVID-19 severity. The Centers for Disease Control and Prevention (CDC) maintains a chart of hospitalization rates by age. It shows a smooth upward curve with increasing age, and the CDC notes that approximately 8 in 10 U.S. deaths occurred in patients aged 65 and older.
- Viral Load. A September 2020 study published in the journal The Lancet found a significant association between viral load (as measured by viral concentrations in hospitalized patients’ blood) and mortality rates, with higher viral load corresponding to higher mortality. This association underscores the importance of following CDC guidance on wearing face coverings, which when properly worn reduce the number of virus-laden respiratory droplets spread and inhaled by the wearer (per an August 2020 paper published in the Journal of General Internal Medicine).
Separately, the CDC identifies several comorbidities that increase patients’ risk of serious COVID-19 disease. Patients with any of these conditions may face higher COVID-19 treatment costs due to a longer course of illness or the need for additional treatments not indicated in otherwise similar patients (or both). Regardless, the CDC recommends continuing any treatment already indicated for these conditions and keeping at least 30 days’ medication on hand.
- Type 2 diabetes
- Smoking and health issues associated with smoking, such as chronic obstructive pulmonary disease (emphysema and chronic bronchitis)
- Obesity or severe obesity (defined as a body mass index greater than 30 or 40, respectively)
- Heart disease, including heart failure, coronary artery disease, and pulmonary hypertension
- Kidney disease
- Cancer or a history of cancer (but especially in current cancer patients)
- Sickle cell disease
- Compromised immune function due to a prior solid organ transplant (such as a kidney or liver transplant)
- Pregnancy and hormone therapy (which may increase the risk of blood clots in COVID-19 patients, according to the Journal of Clinical Hypertension)
The CDC also identifies a broader array of potential comorbidities for COVID-19 based on a vast and ever-evolving body of evidence. These conditions may increase patients’ risk of serious COVID-19 disease, but the evidence isn’t yet as strong as it is for other conditions. As the medical community learns more about COVID-19, the link between some of these conditions and severe disease might strengthen — or turn out to be insignificant:
- Moderate to severe asthma
- Cerebrovascular disease (a disease affecting blood flow and supply to the brain)
- Cystic fibrosis
- Hypertension (high blood pressure)
- Certain conditions that contribute to compromised immune function, including HIV, prior blood or bone marrow transplant, and use of immune-weakening medicines (including corticosteroids)
- Certain neurological conditions, including dementia
- Liver disease
- High BMI that doesn’t meet the obesity threshold
- Pulmonary fibrosis
- Thalassemia (an inherited blood disorder)
- Type 1 diabetes and gestational diabetes
Note that being young and having none of the listed conditions doesn’t guarantee you won’t experience a severe case and require more expensive treatments. In fact, according to The Atlantic, healthy young people are still at high risk of developing crushing long-term or even life-threatening symptoms, and the jury’s still out on just how serious (and therefore expensive) any permanent complications may be.
Cost of COVID-19 Treatment: Common Treatments for Mild, Moderate, & Severe Cases
U.S. health care pricing is notoriously opaque. Even standard low-cost procedures vary widely in price. According to CostHelper, the full cost of a chest X-ray (before insurance) ranges from an average of $200 to $400, depending on the provider and number of views. Pricing for more complex, costly procedures is even more variable.
That said, there’s enough data to estimate the approximate cost before insurance of common treatments, interventions, and support care for COVID-19. As a general rule, more severe cases of disease cost more to treat. But patients’ actual out-of-pocket expenses vary based on factors like the insurer’s payment share, treatments administered, the length of the inpatient stay, provider pricing and billing policies, and geography.
These pricing estimates don’t include indirect costs, such as unpaid time off work or transportation to medical appointments. Nor do they include costs associated with chronic health issues that may arise after COVID-19 infection, such as chronic cardiovascular, pulmonary or mental or neurological disorders.
COVID-19 Testing: With and Without Health Insurance
Virtually all courses of COVID-19 treatment begin with a COVID-19 test. Although many mild cases of COVID-19 aren’t confirmed by laboratory or rapid testing, it’s best to seek coronavirus testing if you have any inkling you’re infected. That includes identifiable symptoms consistent with COVID-19 or a confirmed or probable exposure to an infected person.
In theory, it shouldn’t cost you anything to find out whether you have this disease. According to the U.S. Department of Health and Human Services (HHS), coronavirus testing is free nationwide at designated community testing sites.
In practice, the reality is a bit more complicated. Due to long lines, gaps in geographical coverage, and other factors, not everyone does (or can) get tested at community testing sites. Instead, many turn to private health care providers and labs where pricing can vary wildly.
According to an analysis by the New York Times, the median cost of COVID-19 testing in private settings comes in around $100. But some labs charge many times that. The Times singles out a North Texas lab that routinely billed more than $2,000 for COVID-19 tests — and sometimes more than $6,000 per test.
If you plan to seek testing from a private lab, confirm pricing upfront. Do this even if you have health insurance coverage, as not all insurance policies cover the full cost of COVID-19 testing and policies are less likely to cover the full cost when that cost is egregious.
Home Treatment for Mild COVID-19
Most COVID-19 cases are mild enough to treat at home, according to the World Health Organization. In such cases, the Mayo Clinic recommends treatments including the sort of self-care doctors advise for the common cold and mild bouts of seasonal influenza: hydration, bed rest, and over-the-counter medications such as fever reducers and cough suppressants.
The total cost for home treatment of truly mild COVID-19 cases is likely to come in under $50. If you have a well-stocked medicine cabinet and tea supply, it might require no out-of-pocket spending at all. Common over-the-counter medications used to treat COVID-19 include:
- Fever Reducer or Pain Reliever. The Mayo Clinic recommends acetaminophen to reduce fever associated with COVID-19. Ibuprofen might be more effective for pain relief in patients with intense body aches or headaches. Both are relatively cheap. A large acetaminophen bottle (500 to 600 capsules) costs anywhere from $6 to $12 at major retailers.
- Cough Suppressant or Medication. Expect to spend $5 to $8 for a retail-size bottle of over-the-counter cough medicine, per GoodRx. A bulk pack of 400 medicated drops costs about $17 on Amazon, but you can find smaller packs (fewer than 100 drops) for $3 to $4 at major retailers.
- Nonmedicinal Comfort Treatments. This category involves whatever creature comforts you require, such as tea with honey to soothe a sore throat. Expect to spend $3 to $4 per 18- or 20-pack of herbal tea (or up to $10 for a bulk pack) and $3 to $10 for a retail-size bottle of honey, depending on the size and quality.
If you’re a member of a higher-risk group, your doctor might also recommend the following precautions for your at-home COVID-19 treatment course:
- Home Blood Pressure Monitoring. Because patients with hypertension are at greater risk for developing serious COVID-19 disease, your provider may recommend regular in-home blood pressure monitoring, per the July 2020 guidance published in the Journal of Clinical Hypertension. Costs for top-of-the-line monitors can come in around $200, but a serviceable budget-friendly blood pressure monitor costs less than $75, according to WebMD.
- Home Blood Oxygen Monitoring. Hypoxia (low blood oxygen levels) can be an early indication of worsening COVID-19 disease. Fortunately, you can easily check your blood oxygen at home with a low-cost fingertip monitor, which can cost less than $20. Fancier (and potentially more accurate) products run $30 or more. According to The BMJ, in-home blood oxygen monitoring is standard practice for the management of mild COVID-19 in the United Kingdom.
- Prescription Blood Thinners. If your provider determines you have an elevated risk of coagulopathy (impaired clot formation) due to COVID-19 during pregnancy or another preexisting condition, they may prescribe blood-thinning medication. According to GoodRx, out-of-pocket pricing for prescription blood thinners varies from around $100 for 10 daily doses to more than $400 for a month-long course. (Doctors typically prescribe higher-priced blood thinners, such as Arixtra (fondaparinux) to treat existing clots rather than prevent clots.) According to the American College of Obstetricians and Gynecologists, one of the cheapest options, enoxaparin sodium (brand name Lovenox), is safe to use in pregnancy.
If your symptoms worsen during your at-home treatment period, you may need to seek medical attention at a primary care clinic, urgent care (walk-in) clinic, or hospital emergency room. According to the CDC, COVID-19 symptoms that demand emergency care include:
- Trouble breathing
- Persistent chest pain or pressure
- New confusion
- Bluish lips or face
- Inability to wake or stay awake
However, if you’re concerned about any of your COVID-19 symptoms (or suspected COVID-19 symptoms if you haven’t been tested), don’t wait until you’re in serious distress to consult a health care professional. Your consultation cost depends on where you choose to seek care:
- Primary Care Clinic. If you already have a primary care provider, they could be your most cost-effective option. If your health insurance plan covers routine office visits, you’ll pay little if anything out of pocket — figure $20 on the high side as a copay. Without insurance, expect to pay up to $200 for an office visit (Blue Cross Blue Shield of Massachusetts estimates $130 to $180, but pricing varies widely by location and provider). In either case, because the virus responsible for COVID-19 is highly transmissible, it’s possible (if not probable) the consultation will happen over the phone or a video link.
- Urgent Care (Walk-In Clinic) Visit. A provider consultation at a walk-in or urgent care clinic, usually with a nurse practitioner or physician assistant, typically costs $100 to $200, according to Solv. If they need to perform a chest X-ray, expect to pay $200 to $400 more.
- Emergency Department Visit. A hospital emergency room costs significantly more than an urgent care clinic, but it’s warranted for severe or worsening COVID-19 symptoms like shortness of breath or chest pain. According to CostHelper, an emergency room visit runs anywhere from $150 to $3,000, with prices higher for visits requiring more diagnostic or supportive care. Expect to incur costs at the middle to high end of this range.
Hospitalization for Moderate to Severe Cases of COVID-19
Moderate to severe COVID-19 may warrant hospitalization. Noncritical cases may warrant only brief hospital stays followed by at-home illness management. On the other hand, severe cases of COVID-19 involve a significant risk of critical illness and complications, such as acute respiratory distress syndrome and multiorgan failure, according to the CDC. These complications necessitate prolonged hospitalization and aggressive intervention. They’re also most likely to warrant the use of experimental therapeutics, depending on their availability and indication.
According to People, though he didn’t personally pay for it, U.S. President Donald Trump’s three-day hospital stay would have cost the typical American more than $100,000. The BBC reports his treatment included a battery of diagnostic procedures and laboratory tests and aggressive treatment with high-flow oxygen, systemic steroids, an antiviral drug, and an experimental antibody serum. Notably, Trump’s six-figure hospitalization was not reported to include a stay in the ICU, which would likely have further increased his treatment costs.
That said, hospitalization costs vary widely by location, hospital system, and disease severity (notably, whether the disease requires transfer to a more expensive intensive care ward). At about $10,000 per day, HealthCare.gov’s estimate of inpatient COVID-19 treatment costs is lower than what Trump’s reportedly cost — though it likely equates to a lower standard of care. In particular, the experimental antibodies Trump received aren’t yet widely available and may never be included in standard care routines, even for critically ill patients, without aggressive and concerted action by world governments, manufacturers, and distributors, according to Health Affairs.
It’s crucial for any would-be patient to understand that all hospital stays involve a bevy of care-related and incidental expenses that contribute to the total cost of hospitalization. Most, like IV drips and vital sign monitoring, aren’t unique to COVID-19 wards. Moreover, what begins as a brief stay can escalate into a prolonged admission if symptoms worsen. These expenses all contribute to the total cost of inpatient care.
In addition to the incidental and care-related expenses all hospital patients can expect to encounter, some specific treatments are warranted for hospitalized COVID-19 patients. Per Healthgrades and the Mount Sinai School of Medicine, these treatments may include:
- High-Flow Oxygen Treatment. Many hospitalized COVID-19 patients receive high-flow external oxygen. Hospitals generally don’t list patient pricing for oxygen treatment, and pricing varies widely by health system and insurance provider. But it’s reasonable to expect a hospital stay involving oxygen treatment to cost several thousand dollars per day. A 2014 study published in the journal Hospital Pediatrics found that the average daily admission cost of children receiving high-flow oxygen in the hospital ranged from about $2,866 to about $3,066. However, this range doesn’t necessarily reflect the total billed cost of care for a COVID-19-related hospital stay involving high-flow oxygen treatment.
- Blood Thinners. Doctors are more likely to prescribe anticoagulants (blood thinners) for hospitalized COVID-19 patients than those treating less severe disease at home. In a hospital setting, anticoagulant treatment is likely to cost more than self-administered prescription treatment. A 2018 study published in the journal Clinical and Applied Thrombosis/Hemostasis found average daily hospitalization costs for patients admitted for acute blood-clotting disorders in the neighborhood of $800 to $1,000. But this range doesn’t necessarily reflect the total billed cost of a COVID-19-related hospital stay requiring blood-thinning medication.
- Systemic Steroids. According to Becker’s Hospital Review, current practice is to treat COVID-19 patients receiving oxygen (including Trump) or on ventilators with dexamethasone. According to the March 2020 RECOVERY trial conducted in the U.K., treatment with this low-cost steroid significantly reduced COVID-19 mortality in seriously ill patients experiencing respiratory complications. “Low-cost” is an understatement: According to GoodRx, Dexamethasone is available in U.S. pharmacies for under $15 for 60 (4-milligram) tablets (which Medscape says is enough for a course lasting about a week to well over a month, depending on dosage). In a clinical setting, dexamethasone treatment likely costs more due to markups, which can approach or exceed 500%, according to reporting cited by Becker’s Hospital Review.
- Antiviral Drugs. The antiviral drug remdesivir, which Trump received, also shows promise in seriously ill COVID-19 patients. However, it’s not as widely available as dexamethasone and costs far more. According to FiercePharma, its fair value comes in well over $4,000, though generic alternatives could cost as little as $400 to $800, give or take. Separately, the company that makes remdesivir has said (via CNBC) that the typical insured U.S. patient will pay a little over $3,000 for a standard five-day course of treatment. Of course, many seriously ill COVID-19 patients aren’t in a position to refuse potentially lifesaving treatment over cost concerns.
- Monoclonal Antibodies. This experimental treatment, which Trump also received, essentially utilizes neutralizing antibodies from recovered COVID-19 patients to give sick patients’ immune systems a head start against the virus responsible for the disease. Due to limited supply, not all severely ill COVID-19 patients can expect to receive monoclonal antibody treatments. Those who do can take heart in a recently announced partnership between the HHS and AstraZeneca that could help distribute the treatment at no out-of-pocket cost to patients.
- Mechanical Ventilation. Gravely ill COVID-19 patients may require mechanical ventilation to sustain life. A 2005 study published in the journal Critical Care Medicine using intensive care data from 2002 found that mechanical ventilation contributed $1,522 per day on average to U.S. patient treatment costs. Adjusting for inflation, that amounts to roughly $2,200, according to the CPI Inflation Calculator. However, note that mechanical ventilation is just one of many potential costs incurred by critical care patients since they’ll also continue to receive associated care, such as IV drips and laboratory tests.
- Treatment of Serious Complications. Severe COVID-19 disease can cause a host of potentially life-threatening complications, including stroke, pulmonary embolism, and kidney failure. These complications can be costly to treat. For example, CostHelper pegs the cost of thrice-weekly dialysis treatments for patients with impaired kidney function at a minimum of $1,500 per week. And critically ill patients experiencing multiple complications over periods of weeks or months face truly devastating financial consequences (as well as a significant risk of death). Broadway star Nick Cordero, an otherwise healthy 41-year-old, spent three months in a Los Angeles hospital before succumbing to COVID-19 in July 2020. While in the hospital, People and CNN report, he suffered multiple complications, including respiratory infection, cardiac arrhythmia, internal bleeding, and blood clots resulting in a leg amputation. His family set up a GoFundMe page with an initial donation request of $400,000, which may not be the full amount of the final bill if the family had health insurance.
Out-of-Pocket vs. Covered Costs: What to Expect From Your Insurance Company or Health Care Payer
As with the disease itself, there’s a lot we still don’t know about insurance companies’ approach to COVID-19 treatment. While insurance plans that comply with the ACA should cover most or all costs associated with COVID-19-related consultations, they may cover less of the cost of treatment for moderate to severe disease due to a combination of high deductibles, coinsurance, and out-of-network care (especially in emergencies).
Estimating the Patient’s Share of COVID-19 Treatment Costs
Fortunately, we’re not flying blind. At the very least, using what’s known about how private and government-run insurance works, current and future COVID-19 patients with health insurance can begin to estimate the rough proportion of treatment-related costs — and often a broad dollar-value range — they’re likely to bear themselves. For example, the millions of Americans with ACA marketplace health insurance can expect their insurers to pick up anywhere from 60% to 90% of the total cost of in-network care to treat moderate to severe (but not critical) COVID-19 disease, depending on the plan’s tier.
Meeting the Deductible & Accounting for Coinsurance
All health insurance plans have a deductible, the amount the patient pays for covered services before plan reimbursement begins. (Many plans cover certain basic services, such as preventive care visits, in full. These services don’t count toward the plan’s deductible.) Generally, plans with lower monthly premiums have higher deductibles and vice versa. If your plan has a high deductible, you could find yourself paying thousands of dollars out of pocket for diagnostic and treatment costs related to moderate COVID-19 disease.
Deductibles for ACA-compliant catastrophic plans, which are available to people under 30 and those with qualifying financial hardships, exceed $8,000 for the 2020 plan year, per HealthCare.gov. But any health insurance plan — whether individual or employer-based — with a deductible above $1,400 for individuals and $2,800 for families counts as a high-deductible health plan (HDHP).
Even after meeting the deductible, insurance doesn’t always pick up 100% of covered care and services. Many plans require coinsurance: a percentage of covered costs paid by the patient, usually less than 50% (and often more like 10% or 20%). Still, on a hefty hospital bill, even a modest coinsurance obligation can add up. With 20% coinsurance, you’re on the hook for $1,000 for every $5,000 in billed care costs. That’s $6,000 for a $30,000 bill (the average cost of a three-day hospital stay) or $100,000 for a $500,000 bill (a realistic prospect for a patient with catastrophic COVID-19 complications).
Annual Caps on Out-of-Pocket Expenses
Due to ACA-mandated caps on annual out-of-pocket expenses for in-network covered care, which come in at $8,150 for individuals and $16,300 for families in the 2020 plan year and $8,550 and $17,100, respectively, for the 2021 plan year, patients’ cost-share may be significantly lower than 60% for cases requiring prolonged hospitalization. But this is by no means guaranteed. Per HealthCare.gov, annual out-of-pocket coverage caps exclude:
- Monthly premium payments
- Services not covered by the insurance plan (most routine COVID-19 treatments are likely to be covered, but off-label drug prescriptions and experimental therapies might not be)
- Out-of-network care and services (nearly 20% of emergency department visits occurred out of network in 2017, according to the Kaiser Family Foundation)
- Provider charges above the allowed amount for a particular service
Because these exclusions can be broad — and potentially expensive — it’s crucial to understand what services aren’t covered by your insurance plan and where to turn for quality in-network treatment. Your insurance plan’s website should have detailed answers to both questions.
The most critical factor in determining the final cost of any given patient’s COVID-19 treatment is the severity of the illness. Most cases of COVID-19 are mild enough to ride out at home without requiring hospitalization, specialized therapies, or aggressive interventions like high-flow oxygen or mechanical ventilation.
But COVID-19 is an unpredictable disease that can hit anyone hard — young or old, healthy or infirm. Despite significant improvements in disease management and treatment since the pandemic’s early weeks, there remains no cure — and no guarantee against severe disease. And we still know little about the possible long-term effects of the disease. For that reason, prevention is the best medicine. That means following CDC guidelines, including wearing a store-bought face mask or making a DIY face mask, washing your hands, and practicing social distancing whenever possible.
Have you or someone you know sought treatment for COVID-19? How much did it ultimately cost?