With over 30,900 people dead and more than a 639,000 infected with the coronavirus in the US the last question on a person’s mind should be how they will pay for life-saving treatment.

But as the death toll mounted, a patient who was about to be put on a ventilator in one of New York City’s stretched to capacity intensive care units had a final question for his nurse: “Who’s going to pay for it?”

Those were the patient’s final words to his medical team, Derrick Smith, nurse anesthetist at a New York City hospital wrote on Facebook last week: “Next-level heartbreak – having to hear a dying patient use his last words to worry about healthcare finances.”

In the wealthiest country in the world, the Covid-19 pandemic has exposed the core of a healthcare system that is structurally incapable of dealing with the pandemic. Federal and local governments, health insurers and employers have pledged to help Americans pay their way through this crisis, but to do so requires a dramatic overhaul of a system which has for decades prioritized cost over care.

“As this epidemic makes clear, at any moment, any of us could become sick, could become hospitalized, could be on a mechanical ventilator,” said Adam Gaffney, an ICU doctor in Boston. “And that, in the United States, could mean potentially ruinous healthcare costs.”

Gaffney is president of Physicians for a National Health Plan, a group of more than 20,000 medical professionals who support universal healthcare in the US. PNHP members see first hand the consequences of people being forced to make medical decisions based on cost.

“I’ve heard from patients saying they’ve skipped their inhaler because they couldn’t afford the dose,” Gaffney said. “I’ve heard from patients who’ve gone for years without primary care because they were uninsured and wound up in the ICU.”

There were 27.9 million people without health insurance in 2018 and that figure is projected to increase by millions.

There were 27.9 million people without health insurance in 2018 and that figure is projected to increase by millions because of record-high unemployment. In the meantime the US has 639,000-plus detected coronavirus cases and more than 30,900 deaths, the true numbers will be far higher.

The US government and major health insurers said they are covering the costs of Covid-19 testing and treatment, but fear of bankrupting costs and the byzantine complexities of the system leave unanswered questions about whether people will even seek care, let alone escape a potentially crippling medical bill weeks or months later.

How much testing and treatment costs individuals depends on if the patient was insured, how they were insured, and whether they survived. For example, a company that pays for its staff’s health insurance could decide not to cover an employee’s treatment, even if the health insurance company it’s using had said it would waive Covid-19 related payments.

Facebook Twitter Pinterest The intensive care unit at the St Vincent medical center in Los Angeles. Photograph: Damian Dovarganes/Associated Press

And simply overcoming the American instinct to question how much medical treatment costs is a hurdle in the pandemic.

Since 2006, 30% of Americans each year on average have delayed any sort of medical treatment for cost, according to the polling firm Gallup. In that time, 19% of Americans each year on average have delayed treatment for a serious condition, according to Gallup’s December 2019 report.

More Americans are afraid of paying for healthcare if they became seriously ill (40%) than are afraid of getting seriously ill (33%), according to a 2018 poll by the University of Chicago and the West Health Institute.

It’s hard to fight an epidemic if people are afraid to go to the doctor Adam Gaffney

“It’s hard to fight an epidemic if people are afraid to go to the doctor, to be seen in the emergency room,” Gaffney said. “It could mean some people not getting tested, it could mean some people delaying getting care and potentially harming their own health.”

Medical clinic closures and job losses in a pandemic

The pandemic crisis is being further exacerbated by the system’s devotion to profits over people. Medical workers are being furloughed and losing jobs because of the pandemic – including those on the frontlines – as their employers seek to cut costs.

Alteon Health, a private-equity backed company which employs about 1,700 emergency medicine doctors and other physicians, said it would temporarily stop providing benefits including paid time off, according to the health website STAT.

While intensive care units and emergency rooms are billing sky-high figures, there has been a pause on non-essential care that has, in turn, cut medical system profits.

Without high-margin treatments such as physical therapy, cosmetic surgery and orthopedic procedures, medical systems are struggling to pay salaries and cover administrative costs.

The American Academy of Family Physicians projected 60,000 family practices will close or significantly scale back by June and 800,000 of their employees will be laid off, furloughed or have their hours reduced.

And in hospital corridors across the country, staff aren’t just extra mindful of a dry cough and high temperature, but also that their salaries and work equipment are dependent on the bottom line.

Facebook Twitter Pinterest An EMS worker is seen outside NYU Langone Health hospital in New York City. Photograph: Noam Galai/Getty Images

Joe Maginn, an ER nurse in Madison, Wisconsin, said: “The bottom line has always been very forefront and this now puts into an extra level of being conscious on our mind to not waste money.”

Maginn and his wife, who is also a healthcare worker, are on alert for their own healthcare costs.

“If we do get sick and need to be hospitalized, it hits us financially with the insurance and those kinds of payments, but it also hits us financially because we’re not able to work any longer,” Maginn said. “It’s a double whammy for the healthcare workers doing this right now.”

His health insurance, which also covers their three children, costs $5,000 a year plus the money they set aside for out-of-pocket costs in a tax-free account.

“We work for the hospital, it should be that we would have the most access to it [healthcare], but unfortunately yeah, that’s not how our country is set up.”

Congress has allocated $100bn to help hospitals. On Friday, the White House said hospitals that accept the funds will not be allowed to use two common billing practices: to bill uninsured patients or bill them for getting care from a doctor who is at the hospital, but not directly employed by it.

Like other parts of the planned government response, questions remain about just how effective that money will be in addressing the convoluted healthcare landscape and if it will arrive in time to save jobs and clinics.

Financial burden on the frontlines, not the insurers

This major disruption to the US healthcare system may leave nurses and doctors jobless, but there are early indications insurance companies could be insulated from the damage.

Not only did health insurance companies enter the crisis with capital, several analysts have anticipated these companies could have lower costs because fewer people are seeking routine medical care.

David Blumenthal, president of the global health thinktank the Commonwealth Fund, said people who have coverage year-round will still be paying premiums, while insurers have fewer procedures to cover.

“We will continue to pay our premiums, because we know that we could get coronavirus and end up in the intensive care unit and have to pay hundreds of thousands of dollars if we don’t have insurance,” Blumenthal said. “So we’re going to keep paying, but we’re not going to the doctor unless we absolutely need to. So that’s all good news for insurance companies.”

At the same time, the 16 million people who have lost their jobs in the past three weeks will put an increased burden on the healthcare system if they join the ranks of the uninsured or those who use Medicaid, government health insurance for low-income people.

Facebook Twitter Pinterest A refrigerated truck is seen next to Wyckoff Heights medical center in New York City. Photograph: Pablo Monsalve/Corbis via Getty Images

Blumenthal said there were also knock-on health effects to the economic crisis, such as depression from income loss and malnutrition, which would make people more susceptible to illness.

Benjamin Sommers, professor of health policy and economics at Harvard TH Chan school of public health said there are few signs the pandemic is driving the Trump administration to reflect on the healthcare system.

“We’ll have to see where the public ends up settling on in terms of what it demands from public officials in response to this epidemic,” said Sommers, a practicing primary care physician.

The ICU doctor, Gaffney, said he was certain the way healthcare is financed in the US is exacerbating the overall harm of the epidemic.

“At a time of soaring unemployment and at a time of deepening recession, people are going to be losing coverage and seeing more and more medical bills if they get sick,” Gaffney said. “That doesn’t make any sense.”