WASHINGTON -- Marilyn Cortez, a retired cafeteria worker in Houston with no health insurance, spent much of July in the hospital with covid-19. When she returned home, she received a $36,000 bill that compounded the stress of her illness.
Then someone from the hospital, Houston Methodist, called and told her not to worry -- President Donald Trump had paid it.
But then another bill arrived, for twice as much.
Cortez's care is supposed to be covered under a program Trump announced this spring as the coronavirus pandemic was taking hold -- a time when millions of people were losing their health insurance.
"This should alleviate any concern uninsured Americans may have about seeking the coronavirus treatment," Trump said in April about the program, which is supposed to cover testing and treatment for uninsured people with covid-19, using money from the federal relief package passed by Congress.
The program has drawn little attention since, but a review by The New York Times of payments made through it, as well as interviews with hospital executives, patients and health policy researchers who have examined the payments, shows the plan has caused confusion at participating hospitals, which in some cases have mistakenly billed patients such as Cortez, who should be covered by it.
Few patients know the program exists, so they don't question the charges. And some hospitals and other medical providers have chosen not to participate in the program, which bars them from seeking any payment from patients whose bills they submit to it.
Large numbers of patients have also been disqualified because covid-19 has to be the primary diagnosis for a case to be covered, unless the patient is pregnant. Since hospitalized covid-19 patients often have other serious medical conditions, many have other primary diagnoses. At Jackson Health in Miami, for example, only 60% of uninsured covid-19 patients had decisively met the requirements to have their charges covered under the program as of late July, a spokeswoman said.
"This is not the way you deal with uninsured people during a public health emergency," said Sara Rosenbaum, a professor of health law and policy at George Washington University.
The program has clearly paid what, in many cases, would be staggering and unaffordable bills for thousands of covid-19 patients. In addition to hospital care, it covers outpatient visits, ambulance rides, medical equipment, skilled nursing home care and even future covid vaccines for the uninsured, "subject to available funding."
It does not cover prescriptions once patients leave the hospital, or treatment of underlying chronic conditions that make many more vulnerable to the virus.
Health care providers in all 50 states had been reimbursed a total of $851 million from the fund as of last week -- $267 million for testing and $584 million for treatment-- with hospitals in Texas and New Jersey receiving the most.
But the Kaiser Family Foundation, a nonpartisan research organization, has estimated that hospital costs alone for uninsured coronavirus patients could reach between $13.9 billion and $41.8 billion.
"The claims have just been so much smaller than anyone would have expected," said Molly Smith, a vice president at the American Hospital Association. "One thing we've heard a fair amount of is just serious backlogs and delays. But probably a lot of claims aren't getting into the system at all because our members have determined they don't qualify."
The association says some hospitals have reported not submitting a substantial number of claims for their uninsured, with estimates ranging from 40% to 70%, because covid-19 was not ruled their primary diagnosis.
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"Either hospitals code inconsistent with ICD-10 rules," said Tom Nickels, an executive vice president of the hospital association, referring to the diagnostic codes that hospitals use for billing, "or they don't get paid even though the patient is clearly getting treated for covid."
Harris Health, a two-hospital public system in Houston, did not bill the federal fund for 80% of the roughly 1,300 uninsured covid-19 patients it had treated through mid-July because many of them also had other medical problems -- most often sepsis, an overwhelming reaction to infection that causes blood-pressure loss and organ failure. In other cases, "an underlying health condition was the primary reason for hospitalization, but was exacerbated by the covid-19 disease," spokesman Bryan McLeod said.
Nationally, the total average charge for uninsured covid patients requiring a hospital stay is $73,300, according to FAIR Health, a health care cost database, although they may be able to negotiate a lower amount.
Reimbursements have varied widely with few obvious explanations. New Jersey providers, for example, have received $72 million in treatment claims while those in neighboring New York have received half as much. Providers in hard-hit Texas and Florida, states that have not expanded Medicaid to cover more poor adults, have received $144 million and $53 million, respectively.
"It's just not clear to me what's going on," said Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, who has looked closely at the program and its claims database.
Despite its limitations, some hospital executives said they liked the program because it paid Medicare rates, which are considerably higher than those for Medicaid, the government health insurance program for the poor, or any normal funding they would receive for charity care.
"This was a really progressive policy we were really surprised by, frankly," said Dr. Shereef Elnahal, chief executive of University Hospital in Newark, N.J., which has received $8.2 million for treating 787 uninsured patients with covid, about a third of its coronavirus patients.