The incipient spread of the coronavirus in the U.S. has laid bare the precarious nature of a health system in which millions of people lack health insurance. The way to avoid rapid spread of the virus is to make sure that people who need access to care get it as soon as possible. But in this country, 30 million people are uninsured and 44 million more are under- insured because they can barely afford to pay the high deductibles and out-of-pocket costs in their plans.

With millions of Americans unable to afford to see a doctor if they become ill with COVID-19, what should we do? As a first step, public health officials should get out the message that anyone who needs care should seek it. We can’t run the risk of having individuals who might be infected go untested and untreated. People should be assured that when they feel ill they can turn to the healthcare system and be confident that they won’t be saddled with a ruinous bill.

Yet in an ominous moment last week, Secretary of Health and Human Services Alex Azar said he couldn’t promise that a coronavirus vaccine would be affordable to all when it becomes available. He later said the government would try to make vaccines affordable. What’s needed is for federal, state and local public officials to offer strong assurances to the public that vaccines would be offered free of charge or nearly so. The Senate is expected this week to pass a $8.3-billion emergency spending bill approved by the House on Wednesday that includes about $300 million aimed at making the vaccines more affordable, but more funding may be needed to ensure broad access.

We should also move quickly to make Medicaid coverage available to more people. The Trump administration has sought to limit coverage and federal support for Medicaid. Now in the face of this potential epidemic, it needs to reverse that approach. While the administration is considering using a national disaster program to pay hospitals that treat uninsured patients infected with coronavirus, it also needs to make sure people have access to screening for the virus and primary care before their conditions become acute.


Medicaid is built to deal with broad-scale public health crises. For example, when lead-contaminated water threatened the health of the residents of Flint, Mich., in 2016, the federal government provided funding to the state to expand Medicaid for pregnant women and children. In New York City, after the attacks of 9/11, local, state and federal officials developed the Disaster Relief Medicaid plan that suspended federal Medicaid enrollment requirements to enable low-income New Yorkers to enroll quickly. After Hurricane Katrina, the federal government allowed states to temporarily cover evacuees from states hit hard by Katrina in their Medicaid programs, with the federal government picking up the tab.

The Trump administration could demonstrate similar leadership on coronavirus. It could allow states to greatly simplify Medicaid enrollment by creating a one-page application form and keeping people continuously enrolled without the need for constant recertification.

The administration could also allow states to temporarily increase Medicaid eligibility higher up the income scale in all states beyond their current income limits. Thirty-six states and the District of Columbia have expanded their Medicaid programs under the Affordable Care Act to cover people with incomes of up to 138% of the poverty level. But 14 states have not, leaving more than 2 million people uninsured. Another option is for Congress to pass legislation to fully fund expanded Medicaid coverage for these states at least temporarily to encourage their participation.

The United States has long struggled with the notion of shared risk when it comes health coverage. But insurance markets and health systems work best when everyone is included. That is why all industrialized countries have universal coverage and why most of them consistently outperform the U.S. on most measures of healthcare access, affordability, health outcomes and overall costs.


The particulars of a viral epidemic — a risk shared by us all — shows we have a shared responsibility to confront it together to protect ourselves, our neighbors and strangers with whom we share the world. In dealing with a public health crisis, we can’t separate individual interests from those of the community. Likewise, health insurance coverage has to cover everyone if we want a system that works effectively and efficiently. The coronavirus, whether it becomes a full-blown epidemic or not, demonstrates that the health system cannot leave anyone out.

Sara R. Collins is vice president for healthcare coverage and access at the Commonwealth Fund. David Blumenthal is president of the Commonwealth Fund.