Gary Easley was worried as he took a bus to the pharmacy at West Virginia Health Right, a free clinic that has stood for decades in Charleston, West Virginia. Normally, he goes to Walgreens and Kroger to get the nine prescriptions he relies on for his high blood pressure and high cholesterol, diabetes and mood swings, leg pain and lung trouble.
But three weeks before - on March 17, the day West Virginia would become the last state to confirm its first coronavirus case - Easley was summoned to the general manager's office at the Four Points by Sheraton at 9:30 a.m. His job of five years as the hotel's morning-shift chef, he was told, was ending in a half-hour. His health benefits ended two weeks later.
Easley, out of a job and out of a health plan, and Health Right, swamped with new patients, represent a ripple effect of the novel coronavirus sweeping the United States. In a nation where most health coverage is hinged to employment, the economy's vanishing jobs are wiping out insurance in the midst of a pandemic.
No one has a count of exactly how many people have lost their health plans, but there are clues. About 22 million workers have filed unemployment claims since mid-March, according to the most recent federal figures, and that includes only the people who have gotten through to clogged state workforce offices. The latest census data show that job-based coverage accounted for 55 percent of Americans' health insurance, though the kinds of work disappearing the most - restaurant jobs and others in the service industry - have always been less likely to offer health benefits.
The Economic Policy Institute, a nonpartisan think tank, estimates that 9.2 million U.S. residents were at high risk of having lost coverage during the past four weeks. The consulting firm Health Management Associates forecasts that perhaps 12 million to 35 million people will lose job-based insurance because of the pandemic, on top of the 27.5 million who were uninsured before the virus arrived.
In the small state of West Virginia, as many as 30,000 people can be expected to become uninsured, the consulting firm forecast estimates.
"Any safety-net providers, we see it coming down the track like a big locomotive," said Angie Settle, Health Right's chief executive. "When you are a free and charitable clinic, everything we have is based on grants and begging, and we already are at capacity."
The clinic is getting 15 to 20 calls a day from newly uninsured people who want to come for care - many of them middle-class families, unlike its usual clientele of working poor and homeless.
Even with what Settle calls "an absolute lockdown" on visits that are not emergencies, the clinic has accepted 113 new patients over the past 30 days, compared with 72 during the same period a year ago. They are not infected with the coronavirus, though the clinic is doing testing in a tent out back and at a nearby soup kitchen. They just need urgent help.
The greatest pressure is on the pharmacy. Typically, Health Right spends about $10,000 a month on medications, even with pharmaceutical companies donating some drugs. "And now we are spending that a week," Settle said.
Some existing patients want more pills, fearful medicine will become unavailable. Some drug manufacturers have ratcheted up prices. And some people, such as Easley, are turning to Health Right so that chronic conditions do not flare out of control.
"My battle," said Jack Whitley, the clinic pharmacist, "is making sure [new patients] qualify, asking for W-2s, pay stubs," and, often, proof of layoffs.
When Easley still had his job and his hospitality industry health plan, co-pays on his prescriptions cost $140 a month, he said. If he had to buy them on his own, they would cost $2,007 a month, including more than $900 for insulin and syringes alone, according to figures from Health Right, which gave him the medications free, delivered at the curb.
"That's a blessing," said Easley, 56.
For a quarter-century, he worked at the hotel across from the Kanawha River, which runs through town. After Sheraton took it over five years ago, he worked seven days a week until he began taking Sundays off.
He was the first to arrive in the kitchen, taking the 4:10 a.m. bus downtown from his apartment building in time to start at 4:30 a.m. Sometimes, he stayed through the lunch shift, getting enough time at $12.40 an hour to make about $18,000 a year.
The morning he and a dishwater were summoned to the general manager, he already had prepped for lunch and was cleaning up. "I kind of had a feeling something was going on," Easley recalled.
Even though West Virginia still didn't have a covid-19 case - Gov. Jim Justice, a Republican, would announce the first, 300 miles northeast in Shepherdstown, that night - the restaurant had few customers. And Easley had been watching the news.
The general manager told him he would be the first rehired, he said. That didn't help him now.
Two days later, Easley was on the phone with a human resources specialist at Sheraton headquarters going over separation details. She asked whether he was going to pay the $299 to keep his insurance going for April.
"I don't even have that," he replied, unsure how he was going to pay $618 in rent and utilities.
In that case, she told him, his health plan's last day would be March 31.
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The largest and oldest free clinic in West Virginia, founded in 1982, West Virginia Health Right is housed in a two-story brick building on Charleston's east end, not far from the state Capitol.
After 23 years as a nurse practitioner, clinical coordinator and now chief executive, Settle has been witness to enough economic trauma in the Kanawha Valley to fear what is coming. "I'm a very optimistic person, but I don't know how we are going to recover from this," she said. "I really don't. I'm scared."
She has watched the coal industry decay and factories close. She has been thinking lately back to the 2014 water crisis, when a chemical used to wash coal spilled into the Elk River just upstream, forcing 300,000 people not to use contaminated tap water for days or weeks.
"A lot of the restaurants were closed, hair salons," she said. "And that wasn't even statewide." Some small businesses never recovered, and she thinks that now "it's going to be so far-reaching. . . . In our area, especially, a lot of these stores and different businesses are not ready to sustain something like this."
The pressure on the clinic so far "is nothing," she said. "It's the aftermath I'm worried about."
She knows that next month will be worse than this one, once more people's health benefits end April 30.
Among them is Greg Litvin, 53, who moved with his wife and two children to Charleston six years ago for a software sales job. In August, he started working for Thryv, a successor to the Yellow Pages, selling business automation and marketing plans.
By March 25, when his manager in Thryv's Dallas headquarters and a human resources representative called to say his job was being eliminated, most of the small, local companies that were his customers had shut down.
His wife and 23-year-old son and 19-year-old daughter - both living at home - are covered through her job with a medical supply company. Her earnings have just been cut by 40 percent, and Litvin was expecting to make nearly $80,000 his first year with Thryv. They are uncertain they can afford to add him to her health plan.
The April 30 end to his Cigna insurance policy, with its $300 premium every two weeks, is a problem. A recent MRI exam showed brain lesions that stumped his doctor, who referred Litvin to a neurosurgeon, who referred him to a neurologist, with whom Litvin had a telehealth appointment days ago.
The neurologist ordered a different MRI. Litvin is trying to get it scheduled before the end of the month but isn't sure he can. The last MRI required a $391 co-pay. It would have cost more than $1,400 if he'd had to pay on his own, and that test was simpler than the one he needs now.
"This probably sounds really strange, but I've been more stoic about it than I thought I would be," Litvin said. "It's a worldwide situation. . . . Lives are being disrupted. There's a strange feeling of, 'I'm not alone in it.' It makes me, as a husband and a father, not feel as much of a failure."
People around town are losing all kinds of work.
Katrina Wright had pleaded with her husband, a union electrician, to come home from Ohio, where he had been on a huge construction site, helping to build a Google data center. He agreed, knowing the International Brotherhood of Electrical Workers was allowing furloughs.
A few mornings later, she laid off the two women who worked with her in her small cleaning business, worried she could be exposing them and their families to the virus and that they might be exposing their customers. Early that evening, she sent her customers a text: "With a heavy heart as a business owner during this life-changing pandemic, we will indefinitely close. . . . At the end of the day, we need to look out for our clients and ourselves. We will do our part in flattening the curve. Please understand our decision and keep us all in our prayers."
If her husband kept paying into the union health fund, he could still get his family insurance, but it would cost $1,000 a month, and the only money coming into the house now is $1,200 in unemployment benefits from Pennsylvania, where he worked last year. He hasn't gotten through to West Virginia's workforce agency.
So they became uninsured April 1, even though everyone needs care. Her 13-year-old son has autism. Her daughter gets migraines with symptoms that mimic a stroke. At 50, her husband has Raynaud's phenomenon, a disorder in which blood vessels spasm, leading to decreased blood flow in cold or under stress. At 39, she is being treated for high cholesterol and slightly elevated blood pressure.
Wright has always read medical information, not wanting to be a mother who rushes her children to doctors.
Still, she said, "It's scary. I can only treat so much at home."
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Anthony Paranzino is the only employer he knows still paying for health benefits.
He owns Tony the Tailor, a fine menswear shop in an old Masonic Temple building in the center of Charleston's historical district. His father opened it as a tailor's shop in 1974, and Paranzino began working there when he was 9, learning the tailor's craft until they shifted to selling high-end suits, and his father handed over the business in the early 1990s.
In normal times, he has two employees, as well as his wife and a retired woman who still helps out. By early March, the apparel business was already suffering. It was impossible to get fabric from Italy or componentry from China - countries the coronavirus invaded sooner than it did the United States.
The shop's last day open was March 13. He figured furloughing his workers then would let them apply for unemployment benefits before it got too crowded.
Thursday evenings were always when he wrote out paychecks. That next Thursday, Paranzino said, "I cried like a baby. It was the first time I didn't have to make payroll on Thursday night in 30-some years. That's when the reality set in."
He continues to pay for health insurance. Usually, he pays half of his workers' premiums, but he is picking up 100 percent for now. "They are great employees, I didn't want to leave them hanging."
It is costing him $2,361 a month. "I can't do it indefinitely," he said, with his sales volume down 70 percent, even with some online orders still coming in.
Near his shop in the historical district, only the bank drive-through across the street is open. A new branch of West Virginia University's law school is shuttered. So is a political consulting firm next door and the Art Emporium, a gallery and framing shop behind him. A block away on Capitol Street, the bars are closed, and some restaurants are open for curbside pickup only.
These mostly workless workplaces within sight gave Paranzino the idea for a nonprofit he has just formed with a lawyer friend. Using his empty shop as the headquarters, they are raising money for laid-off service industry workers, to give a little help with rent or food or utilities. Since the effort began a few weeks ago, about 500 people have applied. The project has raised $26,500 and sent out $10,500 in rent aid and $6,000 in $50 Kroger grocery cards.
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The testing that Health Right is doing in the tent and at the soup kitchen has not detected anyone with the coronavirus, though 111 people in Kanawha County have tested positive, the most in the state. Across the river from the clinic, Charleston Area Medical Center's Memorial Hospital has taken in the area's only covid-19 patients sick enough to need such care. The hospital has admitted 27 infected patients. Ten are still there. Sixteen have been discharged. One has died.
The hospital has been more fortunate than many. None of the covid-19 patients it has admitted lacked health insurance, according to Dale Witt, the hospital's spokesman.
Nationwide, an analysis by the Kaiser Family Foundation, a health-policy group, has estimated that, throughout the pandemic, uninsured coronavirus patients will cost hospitals $13.9 billion to $41.8 billion.
On April 3, Vice President Mike Pence announced the Trump administration was planning to pay hospitals for treating uninsured coronavirus patients, relying on part of a $100 billion fund Congress recently designated for hospitals and other providers of health care strained by the pandemic. There are no details yet.
Even if those payments come, they would be less than hospitals are paid for privately insured patients, and uninsured patients would "still be on the hook" for bills from doctors who treat them in the hospital, said Larry Levitt, Kaiser's executive vice president for health policy.
Under the Affordable Care Act, people who lose a job are allowed a special enrollment period to buy a health plan, if they can afford one, through the federal insurance marketplace created under the law. President Donald Trump, a foe of the ACA, has resisted calls to more broadly open HealthCare.gov, the marketplace’s online enrollment system available for six weeks late in the year.
Eventually, some unemployed workers can join Medicaid, public insurance for the poor, if their incomes fall low enough. The thresholds vary by state.
For now, some laid-off workers qualify for COBRA, transitional coverage when people lose jobs. Thryv offered COBRA to Litvin. When he checked on premiums, he discovered medical and dental coverage would cost him nearly $800 a month.
"It's astronomical," he said.
Knowing that government help in regaining insurance is proving piecemeal and iffy, Settle at Health Right is bracing for an intensifying onslaught.
In the past weeks, the clinic has sent out about 10 emergency requests for extra grant aid from the foundations and others that help prop it up in normal times.
As for Easley, he is grateful to an old friend who mentioned to him that Health Right might be able to help him with his medicines.
But he finds his mornings depressing without the hotel kitchen. “Everybody calls me and checks to see how I am doing,” he said, “because I fed all these people.”