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The faulty foundation of our new post-pandemic normal

Covid-19 vaccines and antivirals can’t fix the US health care system’s inequities.

People in face masks stand in front of a hand-painted sign reading “We will get by. We will survive.”
It will be harder for many Americans — people of color, the uninsured, people in medically underserved areas — to get tested, to get vaccinated, and to get medication prescribed if they need it.
Josh Adelson/AFP via Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

The transition out of the pandemic and back to “normal” relies upon the idea that Covid-19 is, for people who choose to use the available resources, largely a preventable and treatable illness. But that idea is based on a false premise: that the US health system has the ability to deliver equitable care.

In theory, we do have the tools to limit Covid-19’s damage. Vaccines are effective at preventing severe symptoms, especially after one or more booster shots. Two antiviral treatments can ease symptoms for people infected with the dominant omicron BA.2 strain of the virus; a monoclonal antibody cocktail offers protection for vulnerable people if taken before they have been infected. Rapid at-home tests can let people know when they are infected and help them get an early jump on treatment. (Paxlovid, which is the most effective antiviral out there right now, is supposed to be taken within five days of infection.)

Implicit in the bargain that Americans can return to normal as long as they use these tools is the understanding that they’re available to everyone should they need them.

But there is no such guarantee under the American health system, where some people are less likely than others to have health insurance or a primary care doctor, the bare necessities of accessing health care in this country.

It will be harder for many people — people of color, the uninsured, people in medically underserved areas — to get tested, to get vaccinated, and to get medication prescribed if they need it. They will bear more of the risk of getting infected and falling seriously ill as our society continues to move on from Covid-19 by ending pandemic policies like masking requirements for public transportation.

“Who is this is going to affect? Individuals and communities who have been the least resourced, who have always been exposed to the inequities in our health care system,” said Utibe Essien, assistant professor of medicine at the University of Pittsburgh. “We’re going back to a world where people are overexposed because of their jobs, because they have to get on the subway. They are overexposed and underprotected.”

People of color and the uninsured will struggle to access Covid-19 treatments

They are literally underprotected in one sense: Black and Hispanic Americans who are likely eligible for a booster shot are meaningfully less likely to have gotten it compared to white Americans, according to a recent Kaiser Family Foundation survey. Among all adults, the share of people who are boosted is lower among Black (41 percent) and Hispanic people (39 percent) than it is among white people (52 percent).

Vaccinations are supposed to be the first line of defense in the new normal, but they are not 100 percent effective at preventing illness. The people who are generally more at risk of developing serious Covid-19 symptoms (older people and those with chronic health conditions) do still face an elevated risk of developing serious symptoms compared to younger and healthier people.

That’s where the antiviral pills developed by Pfizer and Merck are supposed to come in. When taken within five days of infection, the Pfizer pill in particular can substantially lower the chances of an at-risk person developing serious symptoms. But to take advantage of these treatments requires timely access to health care — and that is another area where existing disparities in the US health system put some people at risk of falling through the cracks.

Black patients (who have a 12 percent uninsured rate), Hispanic patients (20 percent), and American Indian patients (22 percent) are less likely to have health insurance than white patients (7 percent). They are also less likely to have their own primary care doctor: 19 percent of Black Americans say they do not have one, as do 36 percent of Hispanic Americans, 26 percent of Asian Americans, and 25 percent of American Indians, compared to the 16 percent of white Americans who say the same.

Those disparities put up obstacles at every step a patient might face in securing the Pfizer antiviral, Paxlovid. We know uninsured people are less likely to seek necessary health care than people with insurance. But even if you are insured, you would still need to get the drug prescribed by a doctor, and people of color are less likely to have that regular source of care. Reports also indicate that doctors have generally been tepid about prescribing the antiviral drug and, historically, patients of color have been more likely to report that their doctor did not prescribe medication for their ailments. Research into prescribing practices supports those feelings.

The Biden administration’s test-to-treat program is supposed to fill those gaps, by giving patients an option to go directly to their local pharmacy, get tested for Covid-19, and get Paxlovid immediately prescribed if they test positive. The federal government has made a big bet on this program, reserving a fourth of its order from Pfizer for the test-to-treat sites.

But a recent Kaiser Health News report documented how hard it could actually be to get an appointment and get the drug as intended:

It took a KHN reporter in the Washington, D.C., area three hours driving between stores to figure out whether testing was available and antivirals in stock across four MinuteClinic locations — time that few people can afford in general, let alone when they’re sick.

Each store provided test-to-treat services, which could be booked through a kiosk. But three of the stores either didn’t have same-day appointments available or didn’t have the antiviral pills in stock that day.

One of these CVS appointments could cost an uninsured patient up to $100, the KHN reporters noted. Prior research indicates that any kind of cost barrier, even as little as $10, can lead to people skipping necessary medical care.

It’s just one more indignity that the US health system has thrust upon patients.

Even public health experts can have trouble accessing Covid-19 treatments

Farzad Mostashari, a former senior federal health official, recently laid out his own experience after several members of his family had contracted Covid-19, including his at-risk father. He couldn’t simply get the prescription from his dad’s primary care doctor.

His workaround was to schedule a virtual visit with an urgent care clinic (something that, like the CVS MinuteClinic, likely comes at more cost to the patient). His dad’s kidney health presented another hurdle, as the clinic needed to see a recent renal scan to make sure it was safe to prescribe Paxlovid. They finally got the matter resolved, but it was a challenge — even for someone with Mostashari’s experience.

Bijan Salehizadeh, a health care investor, ended up drafting a how-to-get-treatment plan based on the former health official’s tweets. It took two pages, single-spaced, with a lot of notations to walk through the process for getting the antiviral as quickly as possible if you test positive for Covid-19. As the KHN reporters acknowledged after their own hunt for test-to-treat appointments, a lot of people aren’t going to have that kind of time or energy.

But even with these holes in our defenses, the US is pushing ahead with the return to normal. This week’s voiding of the federal mask mandate for airplanes and other public transportation feels like a demarcation point. Even with cases rising, another pandemic response policy is being retired. Society is giving up on the idea that you can avoid being exposed to Covid-19.

That shift will put individuals in tough spots. The subway system they rely on to commute to work may soon have many more unmasked riders. The businesses they work at may be lightening some pandemic policies. And they may have the kind of home life where they live with others who are even more vulnerable to the coronavirus, adding to the risk if they were to bring something home from the job.

And if then they do get sick, they will be contending with a health system that has already fallen short in ways that will make it harder for them to get the treatment they need.

“Uncontrolled spread places the people and groups who are already made most vulnerable at greater risk,” said Arrianna Planey, a health policy professor at the University of North Carolina. “This is especially pertinent as mask mandates have been undermined, and now people who rely on public transit (mostly workers of color) will be even more exposed.”

We do technically have the tools to live with Covid-19. But because of deep inequities embedded in the US health system, vulnerable people won’t be able to take advantage of that promise.