Why you may soon have to pay for that COVID-19 test

The federal government is poised to stop paying for COVID-19 vaccines, tests and treatments in the coming months, shifting the costs onto the public. 

Experts say most Americans are not aware that this will happen and will be in for a major case of sticker shock. They warn without additional protections or funding, the transition to commercialized treatments and preventive services will lead to health barriers.  

“The way that it works in the U.S. [right now] is actually more similar to how a lot of health care works in other countries too. But when the public health emergency ends, it’s going to start looking like health care in the U.S does, which is that it’s complicated and it costs a lot of money,” said Cynthia Cox, an insurance expert and vice president at the Kaiser Family Foundation.

Instead of free access to tests and treatments like Paxlovid, insurance companies and manufacturers will set the price. 

The days of free, easily accessible COVID-19 tests will also likely end. Private insurance may not cover over-the-counter tests anymore, and patients may need a prescription first for a PCR test.

“I don’t know that most people … are aware that things are going to change,” said Sabrina Corlette, a research professor and co-director of Georgetown University’s Center on Health Insurance Reforms.

Vaccines will still be free to people with private insurance, though the cost will likely be reflected in premiums. Even with insurance, patients will likely see costs if they go to an out-of-network provider. 

But the biggest impact will be on uninsured or underinsured Americans, many of whom have jobs that put them at greater risk of COVID-19 exposure. 

“If you’re an uninsured adult, you’re kind of out of luck,” Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, said during a briefing last month. “They’ll have no guaranteed access at all to tests or treatment in a new environment without federal purchasing and protection.”

Two key changes will lead to commercialization: the end of the U.S. government’s public health emergency declaration and the depletion of the federally purchased supply. 

The Biden administration renewed the public health emergency for 90 days on Oct. 13, but it is expected to be the final extension. The Centers for Medicare and Medicaid Services told providers in August to start preparing for a return to pre-pandemic rules as soon as possible.

Officials at the Department of Health and Human Services (HHS) said they will give the public 60 days notice before lifting the public health emergency, which puts the deadline at Nov. 12. 

The White House has been urging Congress to provide billions more in funding to pay for a steady supply of COVID-19 vaccines and treatments, but lawmakers have shown no appetite for doing so.

The federal government has said it anticipates running out of money to purchase and distribute vaccines as soon as January, and expects its supply of therapeutics to be depleted throughout 2023, depending on the specific product.

A top administration official said the plan has always been to wind down federal involvement in procuring and distributing COVID-19 countermeasures, especially now that supply is no longer limited. When stockpiles run dry, the administration will transition the products into the private market.

“Regardless of whether we’re going to get COVID funding, we were going to eventually have to make this transition at some point. Part of the COVID request makes this a little less bumpy,” Dawn O’Connell, assistant secretary for preparedness and response at HHS, said at a news briefing last month hosted by the Kaiser Family Foundation. 

O’Connell said the administration is coordinating with manufacturers to make sure they have enough supply of tests, treatments and vaccines on hand to put onto the commercial market when the government involvement ends. 

“Much of the supplies have gone to the U.S government. We’re currently continuing to make them available, but there’s going to be a point where our supplies run low and their supplies need to ramp up in order to take on this work,” O’Connell said.

“We can calibrate that easier if we’re continuing to be able to purchase these while the manufacturer continues to ramp up. We might not be in a position to be able to do that if we don’t have the funds.”

Health experts and advocates have expressed concern that without the federal government’s involvement, drug companies may start charging exorbitant prices.

Pfizer said it expects to quadruple the cost of its COVID-19 shot, and charge between $110 and $130 a dose once the government contract ends, possibly by early next year. 

Eli Lilly’s monoclonal antibody treatment is already being sold directly to providers at a list price of $2,100 per dose, though it may not be effective against some of newer omicron subvariants. 

With increased prices, consumers with private insurance could face tiered benefits to limit utilization or face medical necessity determinations. 

For the uninsured, the barriers could be huge. And if there’s a winter surge of infections, there could be significant consequences. 

“If we do get another surge, it could be a real problem,” said Corlette. “Testing services will probably not be as widespread. People will face cost sharing, uninsured folks … will have to pay out of pocket for tests and vaccines. So, it’s a potentially scary situation.”

Certain providers, like community health centers, may provide services for reduced prices or for free, and HHS’s O’Connell said the administration is working with manufacturers on ways to help the uninsured maintain access.

But the Biden administration doesn’t have many tools at its disposal.  

“There is no dedicated program for [the uninsured] — rather, we revert back to the imperfections of the U.S. health care system,” Kates said in an email.