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their plan deems legitimate.

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That changed on 10 March, with good news for patients. The US vice president, Mike Pence, told reporters that the nation’s private and government insurance programs would change the way they did business. “All of our major health insurance companies have now joined with Medicare and Medicaid and agreed to waive all copayments [and] cover all treatments for those who contract the coronavirus,” he said. “They’ve committed to no surprise billing, and they’ve committed to encouraging telemedicine.”

But any relief felt by people with health insurance cover will be tempered by the unemployment resulting from the new coronavirus. A survey from the Commonwealth Fund conducted in May and released on 23 June found that 41% of US respondents who said that they or a partner had lost their job since February had relied on that job for health insurance. They now have to find a way to pay for insurance or healthcare on their own.

Sara Collins, a vice president of the Commonwealth Fund, says, “This survey shows how our piecemeal approach to health insurance coverage in the US leaves too many people without coverage, or just a layoff away from losing it.” About two thirds of Americans are covered by private health insurance, and the rest are covered by various government programs.

The reliance on employment for health insurance premiums is just one of many factors that could threaten the US health insurance industry as the covid-19 pandemic presses on. But, while some of its clients may be struggling, the industry is doing just fine.

While there have been occasional anecdotes of exceptions to the vice president’s promise of full cover by insurers, the errors have most often been due to a faulty billing system or a self-insured company trying to dodge its obligations. Public exposure of wrongful billings has so far proved effective enough to remedy the error without regulatory authorities stepping in.

In 2018, private health insurance paid out $1243bn (£1trn; €1.1trn) for healthcare costs, a third of total health expenditures in the US. That could go down this year, as Americans avoid seeking medical care because of fear of infection and physical lockdowns. Hospital visits in the US were down nearly 55% in March and April, in an analysis by Strata Decision Technology.1 By May that trend had apparently bottomed out and even slightly reversed, as patients began to trickle back for delayed procedures.

Medicare, the federal health insurance program for seniors and the largest payer in the US, has been a source of stability, advancing payments to various parts of the healthcare system to help cover for revenue shortfalls. Some private insurance companies have done the same on a more limited basis.

Insurers benefit

When insurers agreed in March to cover all covid associated costs and to forgo out-of-pocket copayments, most considered the deal to be temporary and attached expiration dates. Some companies have extended their initial dates, and the liberal advocacy group Public Citizen is pushing several others to extend waivers that are about to expire. The large insurer-provider Kaiser Permanente, with 12.2 million members, has extended its waiver to the end of the year.

It’s not clear how many delayed or cancelled procedures will take place at a later date—but some certainly will not, either because the patient has died or because staff and physical space are limited in their capacity to absorb the pent-up demand.

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But, despite the lower payouts, the insurance industry doesn’t expect to see any huge windfall profits: it’s heavily regulated at the national and state levels. One provision of Obamacare (the Affordable Care Act) requires that insurance companies must pay fixed minimum percentages of the premiums they collect for medical services (at least 80% for individual and small group policies; 85% for large groups). If their profit margin increases because of deferred procedures in the pandemic it will be within only a narrow margin, and “surplus” revenue must be returned to policy holders. Some insurers have already started sending rebates to their customers.

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