Even for those with insurance, surprise bills for things not covered can add up fast.
President Donald Trump spent three days in the hospital. He arrived and left by helicopter. And he received multiple coronavirus tests, oxygen, steroids and an experimental antibody treatment.
For someone who isn't president, that would cost more than US$100,000 ($152,000) in the American health system. Patients could face significant surprise bills and medical debt even after health insurance paid its share.
The biggest financial risks would come not from the hospital stay but from the services provided elsewhere, including helicopter transit and repeated coronavirus testing.
Trump has praised the high quality of care he received at Walter Reed National Military Medical Center, and has played down the risk of the virus. "Don't be afraid of Covid," Trump tweeted on Monday, before returning to the White House. "Don't let it dominate your life."
Across the country, patients have struggled with both the long-term health and financial effects of contracting coronavirus. Nearly half a million have been hospitalised. Routine tests can result in thousands of dollars in uncovered charges; hospitalised patients have received bills upward of US$400,000 ($608,000).
Trump did not have to worry about the costs of his care, which are covered by the federal government. Most Americans, including many who carry health coverage, do worry about receiving medical care they cannot afford.
For some Americans, the bills could start mounting with frequent tests. Insurers are generally required to pay for those tests when physicians order them, but not when employers do.
The Trump administration made that clear in June, when it issued guidance stating that insurers do not have to pay for "testing conducted to screen for general workplace health and safety." Instead, patients need to pay for that type of testing themselves. Some might be able to get free tests at public sites, and some employers may voluntarily cover the costs. Others could face significant medical debt from tests delivered at hospitals or urgent care centers.
Covid tests can be expensive. Although they typically cost US$100 ($150), one emergency room in Texas has charged as much as US$6,408 ($9,740) for a drive-through test. About 2.4 per cent of coronavirus tests billed to insurers leave the patient responsible for some portion of payment, according to the health data firm Castlight. With 108 million tests performed in the United States, that could amount to millions of tests that leave patients responsible for some share of the cost.
Marta Bartan, who works as a hair colourist in New York City, needed a coronavirus test to return to her job this summer. She received a US$1,394 ($2,118) bill from the hospital running the drive-through site where she was tested.
"I was so confused," said Bartan, who is contesting the bill. "You go in to get a Covid test expecting it to be free. What could they have possibly charged me $1,400 for?"
The bills for the typical American would continue at the hospital, with the routine monitoring that any patient would receive and the drugs provided in the course of care.
Remdesivir, a new coronavirus treatment created by Gilead, costs US$3,120 ($4,741) when purchased by private insurers and US$2,340 ($3,556) with public programmes like Medicare and Medicaid.
Trump also received an experimental antibody treatment from Regeneron. It's currently available to clinical trial participants or to those granted a "compassionate use" exemption. In either situation, the drug would typically be provided to the patient at no charge. This will most likely change, however, when the treatment finishes trials and hits the commercial market. These types of drugs are hard to manufacture, and other monoclonal antibodies cost thousands of dollars.
Health economists are only starting to understand the full costs of coronavirus treatment, just as scientists are mapping out how the disease works and spreads. They do have some early estimates: The median charge for a coronavirus hospitalisation for a patient over 60 is US$61,912 ($94,101), according to a claims database, FAIR Health
That figure includes any medical care during the hospital stay, such as an emergency room visit that led to admission or drugs provided by the hospital.
For insured patients, that price would typically be negotiated lower by their health plan. FAIR Health estimates that the median amount paid is US$31,575 ($47,991). That amount, like most things in American health care, varies significantly from one patient to another.
In the FAIR Health data on coronavirus patients over 60, one-quarter face charges less than US$26,821 ($40,754) for their hospital stay. Another quarter face charges higher than US$193,149 ($293,558), in part because of longer stays.
Many, but not all, health insurers have said they will not apply copayments or deductibles to patients' coronavirus hospital stays, which could help shield patients from large bills.
Uninsured patients, however, could be stuck with the entire hospital charges and not receive any discounts. While the Trump administration did set up a fund to cover coronavirus testing and treatment costs for the uninsured, The New York Times has reported that some Americans without health insurance have received large bills for their hospital stays.
The biggest billing risk for a patient receiving treatment similar to Trump's would probably come from helicopter rides to the hospital.
Air ambulances are expensive and often not in major health insurance plans' networks. The median charge for an air ambulance is US$38,770 ($58,924), according to a study in the journal Health Affairs published this year. When the helicopter trip is out of network — as about three-quarters of them are — patients are left with a median charge of US$21,698 ($32,978) after the insurance payout.
Taking two helicopter rides, as Trump did, could plausibly result in more than US$40,000 ($60,800) in medical debt for patients without access to their own aircraft (though of course most people do not leave the hospital by helicopter).
The financial consequences of a coronavirus hospitalisation could be long-lasting, if a new Supreme Court challenge to the Affordable Care Act is successful. That case argues that all of Obamacare is unconstitutional, including the health law's protections for preexisting conditions. The administration filed a brief in June supporting the challenge.
The Supreme Court hears that case on November 10. If the challenge succeeds, Covid-19 could join a long list of preexisting conditions that would leave patients facing higher premiums or denials of coverage. In that case, coronavirus survivors could face a future in which their hospital stays increase their health costs for years to come.
Written by: Sarah Kliff
Photographs by: Anna Moneymaker
© 2020 THE NEW YORK TIMES