Dr. Carroll is the chief health officer of Indiana University and writes often on health care research and policy.
Vaccines are essential for creating widespread immunity against the coronavirus. But drugs that can treat Covid-19 are also critical to combat the pandemic. This is especially true for places where large numbers of people remain unvaccinated and unboosted. These individuals could benefit from treatment if they get sick. Others, like the immunocompromised, may need additional help to fight off the disease.
Unfortunately, nearly every step of the pathway by which Americans might get these drugs seems designed to prevent it from happening (which makes vaccination even more crucial).
To begin with, the therapies we have, though very helpful, are not ideal in some ways. A course of newer Covid-19 therapies requires a person to take 30 pills of Paxlovid or 40 pills of molnupiravir, a burden many could find difficult.
While Paxlovid seems to reduce the chance of hospitalization and death from Covid by more than 85 percent, recent data show that molnupiravir doesn’t seem to work as well, perhaps reducing hospitalization and death from Covid by only 30 percent. There are also some concerns that molnupiravir, because of how it works, might lead to new variants.
But having drugs, especially highly effective ones like Paxlovid, is critical. And for these medications to succeed they must be taken correctly. People need to start them within five days of an infection, and because of the deficiencies of our testing system and other problems in health care, beginning treatment that quickly is difficult.
Let’s start with diagnosis. If you feel sick, you need a coronavirus test. A P.C.R. test most likely would take at least a day or two to return results, and that’s if you can find the test. An alternative would be to use an at-home antigen test. Like everything else, these tests become scarce when people need them most. The government is sending some to families free if they sign up on a website, but you can get only four per household at the moment.
Any at-home tests beyond that cost money. The Biden administration has pledged to make insurance cover the costs (up to eight a month), but that promise often requires you to pay for them out of pocket and then get reimbursed later.
And that’s if you have insurance. For those who don’t, the administration plans to make tests available at sites in underserved communities, but getting some requires people to know when they’re in and have the ability to pick them up. The uninsured will, very likely, have the most difficulty doing any of this.
If you test positive, you can’t go straight to a pharmacy for the drug therapy like you did for the test. You need a prescription for the medication, which often requires a doctor’s visit. That presupposes that you have a doctor (many people don’t), and that there’s an appointment available. Before the pandemic, fewer than half of people in the United States could get a same-day or next-day appointment with their provider when they were sick.
If you’re lucky enough to traverse this gantlet successfully, though, you now need to get your prescription filled. Most insurance will restrict where you can get your medications paid for, and it’s hit or miss whether that pharmacy will have pills in stock. If not, hopefully they’ll be in a few days later, but those are precious days.
Too few people understand that much of the U.S. health care system is set up to make it harder for people to get care — an attempt to drive down overall health care spending. That’s why your insurance likely has higher deductibles than it used to, and more visits come with co-pays or coinsurance. But poorer people have a harder time covering these costs, so this worsens disparities and makes it harder for those who need help the most to get it.
We see this play out with Covid-19 treatments. A recent study looked at how efficiently and effectively Medicare beneficiaries (all of whom were elderly) received monoclonal antibody therapy from 2020 to 2021 for Covid. It found that those at highest risk were the least likely to be treated, in large part because it was difficult to navigate these hurdles within the 10 days from infection that treatment requires.
It doesn’t need to be this way. The government could continue to send everyone free antigen tests, as other countries do. Physicians could prescribe pill packs to high-risk individuals ahead of time, as is done with EpiPens, so that if they have a positive at-home test, they can start medication immediately. Pharmacists could be more empowered to talk to patients about whether the pills are safe for them and distribute pill packs without a prescription if patients qualify. Insurance companies could change their cost-sharing requirements so that sick people are incentivized to get care for serious illness, not avoid it.
Making changes like these will not be easy. Before the pandemic, possible pregnancy was one of the few “conditions” that allowed for at-home testing and diagnosis. Such tests were heavily opposed by physicians and much of the rest of the health care system. Physician groups have also repeatedly fought empowering pharmacies to provide care. Even if we were willing to make changes, who would pay for them? Our fragmented multipayer system is ill equipped to think and act collectively.
Some of these treatments, like the vaccines, can be lifesaving. They still might not improve things enough here in the United States. That’s not because the medications don’t work well, though. It’s because our health care system doesn’t.
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