By Zeynep Tufekci

Almost two months after President Biden promised to make lifesaving drugs against Covid widely available to Americans, the medications remain hard to get for many, despite supplies, leaving large numbers of Americans to face increased risks of avoidable death and serious illness.

That’s largely because, once again, a dysfunctional health care system that costs more and often delivers less than that of any other developed country has hindered our pandemic response.

As was the case with vaccines, the United States quickly snapped up these therapeutics and accumulated vastly more supply than any other country. These drugs do not replace vaccines but provide crucial extra protections for vulnerable people who number in the millions and who face increased risks as the few remaining public health protections are rolled back.

Paxlovid, an antiviral treatment developed by Pfizer, an American pharmaceutical company, is highly effective for reducing hospitalizations and deaths in high-risk patients, as long as it is started early. This is especially important for elderly or immunocompromised people, since their immune systems are not as robust as others’ against viruses, even when vaccinated. In his State of the Union address, Biden announced a “test to treat” initiative to provide such pills on the spot in pharmacies when someone tests positive.

Reality is much less rosy.

The national map of participating pharmacies in test to treat shows large parts of the country with none. Even in areas where treatment is supposed to be available, it can be hard to get. A Kaiser Health News reporter spent three hours driving around Washington, D.C., before finding a pharmacy where testing was available and the drug was in stock — something we should not expect sick people to do. When trying to book appointments online in several states, the reporter was sometimes denied an in-person appointment after listing upper-respiratory symptoms and a positive coronavirus test, even though the point of the program is to treat people with respiratory illness so they don’t get sicker. Many places did not have any same-day appointments, a big obstacle for a drug that should be given as quickly as possible.

The greater difficulty is that the drug can be prescribed only by a medical doctor, advanced practice registered nurse or physician assistant, especially because it can interact harmfully with many other drugs. It cannot be prescribed by a pharmacist. Many pharmacies aren’t participating in the national program because they don’t have a clinic on site where a health practitioner can assess a person’s eligibility. Even if they have one, managing prescriptions for high-risk people is best done by a patient’s regular doctor, not in a one-off encounter at a pharmacy. Patients who successfully wangle an appointment are asked to bring a list of all their drugs and, I suppose, resolve all the complexities in one sitting.

As further congressional funding has not been approved, the funds used for reimbursement for coronavirus testing have begun to be depleted, so people without insurance or whose insurance doesn’t cover such clinics have to pay for the health appointment out of pocket.

So it’s not hard to predict that many people will be left behind.

What about those with proper health insurance and a primary care physician? Fine, as long as your doctor is aware of the drug and you can get an appointment quickly and then locate the drug.

Several physicians have told me they had to intervene on behalf of their elderly or high-risk relatives who tested positive, calling their health care providers directly to persuade them to prescribe the antiviral. These may be anecdotal, but even Dr. Anthony S. Fauci, the president’s chief medical adviser, noted last week that the drug was “being underutilized.”

If many doctors are unaware of these therapeutics or unsure how patients qualify for them, where’s the effective awareness and education campaign for health care providers?

In the United States, such doctor outreach is often, sadly, left to pharmaceutical companies, which spend tens of billions of dollars each year marketing their drugs to physicians. This has led to heavily promoted drugs getting prescribed even when cheaper, effective alternatives exist. However, Paxlovid received an emergency use authorization, which means that legally, Pfizer cannot directly market it yet, so physicians don’t get even this sort of outreach. This leaves individual doctors on their own for keeping up with new drugs and treatments, even in a pandemic and even when the drug is potentially lifesaving.

Also, it’s not that easy to get a same-day appointment with one’s regular physician, even for those who have great insurance. This makes catching the early treatment window harder. In most places, emergency rooms are always open, but besides being overloaded and understaffed, they are the last places where infected people should congregate or where the elderly or those at high risk should spend hours merely to get access to a crucial drug.

A similar situation is underway for Evusheld, a Covid drug approved in December for the millions of immunocompromised people, like transplant patients and those on medications that can suppress the immune system for conditions like rheumatoid arthritis. In trials, the drug reduced symptomatic infections by about 83 percent. This drug provides them with extra protection for six months as a prophylactic. It’s been approved for months, and Biden also mentioned treatments for the immunocompromised in his State of the Union address. The federal government bought 1,700,000 doses, to be distributed free.

So I guess this is where I should say, “Stop me if you heard this before.”

In March, The New York Times reported that a whopping 80 percent of the doses were sitting unused as the Omicron wave washed over the country. A CNN investigation found desperate patients unable to find the drug, doctors unaware that it even exists and some pharmacies with hundreds of unused doses while others had none. Hospitals like the Mayo Clinic told CNN that they had only a few thousand boxes for the more than 10,000 patients who could benefit from it, while boxes were delivered to medical spas offering Botox or eyelash extensions (and sitting unused). The Detroit Free Press found supplies of Paxlovid and Evusheld unused because physicians weren’t prescribing them. A Kaiser Health News investigation found that government maps of supplies were missing many locations that had doses. This happened even as desperate patients waited for lotteries to allocate some to them. Social media is also replete with stories of despondent patients unable to locate doses or managing to do so after much effort and paying extra when they ended up out of their insurance networks. Meanwhile, at least one infusion center had so many unused doses that it ran out of refrigerator space and declined new shipments.

What makes this all more troubling is that conditions like diabetes and uncontrolled high blood pressure increase the dangers of Covid and the United States has had a worse record on such health indicators than many other wealthy nations.

Not having a regular relationship with a medical provider — too common in the United States — leaves these high-risk people open to confusion and misinformation, especially in the current political environment. People without insurance lagged in being vaccinated at all and will face more obstacles in getting antivirals.

In Britain, which has a national health system, 58 percent of people have received a third vaccine dose. In the United States the number is a measly 30 percent. Well, I should say we think it is; without a national health system, the United States has difficulty keeping track of the numbers. The failure to reach more people with a third dose, shown by the data to greatly help with outcomes, cannot be blamed solely on anti-vaccination attitudes, as 66 percent of the U.S. population had received two doses.

In October 2019, a Johns Hopkins study found the United States more prepared than any other country for a pandemic. Obviously, that prediction did not age well. But taking a look at how the study got it wrong is instructive.

On many of the indicators the researchers examined, the United States ranked high, often in the top five, with one conspicuous exception: access to health care. On that measure, the researchers placed the United States 183rd out of 195 countries. In retrospect, maybe they should have made that the primary criterion.

What is the point of talking about health care access and outlining how it manifests itself in failure after failure, given that the Republican Party seems determined to block progress and even roll back what little improvement we have had with the Affordable Care Act, or Obamacare?

The most important reason is that to do otherwise would restrict the possibilities for change and our political imagination even further. Lowering the eligibility age for Medicare to 60 and then to 55 and expanding the Veterans Health Administration, the largest integrated health care system in the country, to include firefighters, social workers, teachers and others who serve their communities are among the options that should become part of the political conversation.

And any obstacles on the federal level should inspire states to overcome these problems themselves and even build their own systems.

New York City, for example, has created a hotline to provide Covid information, including how to get Paxlovid free, with home delivery, and how those without a doctor can reach one quickly through a telehealth appointment. In the earlier waves, the hotline also connected people with free hotel rooms if they needed to isolate away from their homes. It will also allow people to request delivery of basic supplies like masks and thermometers to their homes. And I’ve seen all this advertised a lot, including on local TV stations. We need more such efforts.

There’s more the federal government can do now, like start a robust physician and patient outreach program and work to clarify and balance the supply of therapeutics for Covid so that millions of immunocompromised people can better protect themselves and high-risk people who get infected can avoid severe disease.

However, states should be aware that this may not be coming and should begin their own programs and maybe even cooperate to build shared infrastructure. Under these political conditions, rescue may not be on its way for a long time, if ever. We can at least try to build better lifeboats, locally, wherever possible.

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