The first real-world consequences of dwindling federal COVID-19 funds have started to be felt in recent days.

Coronavirus tests for uninsured patients are no longer free in some places. That's because the program that reimbursed clinics and hospitals for the testing, as well as for treating uninsured patients with COVID-19, stopped accepting claims last week "due to lack of sufficient funds." Some clinics have already started to turn away people without insurance who come to get tested and can't afford to pay for it.

Free vaccines for uninsured people are next — that funding will run out next week. After that, the vaccines themselves will still be covered by the government — for now — but the costs of administering them will no longer be billed to the federal program.

In another blow to the COVID-19 response, federal shipments of monoclonal antibody treatments to states — drugs designed to keep people infected with the coronavirus out of the hospital — were also slashed last week by 35%, according to Health and Human Services Secretary Xavier Becerra.

Biden administration officials such as Becerra warn that this is just the beginning. They've cited a long list of consequences — short and long term — as they plead with lawmakers to allocate $22.5 billion more for pandemic relief.

At the moment, that request for funding appears stalled in Congress. That has hospitals and public health experts worried that the U.S. will be poorly equipped to identify — let alone manage — whatever happens next with the pandemic.

As hospitals lose money, staff fear future surges

Losing this federal COVID-19 funding is "one additional threat" to safety net hospitals already strained by two difficult pandemic years, says Dr. David Zaas, who leads clinical care for the Medical University of South Carolina's network of 14 safety net hospitals in South Carolina.

He says that even without a pandemic, hospitals that primarily serve low-income patients run on tight margins. Add to that "the decreases in surgeries, as well as the increase in costs from the supply chain and labor, and the unpredictability of the different COVID waves," and it's clear why the pandemic has been so rough.

The Provider Relief Fund has been essential over the past two years, he says. His hospital network has gotten "$9.8 million of hospital reimbursement for predominantly inpatient care of uninsured COVID patients — that is now going away," he explains.

He says the hospital network will continue to test and treat uninsured patients with COVID-19 and won't bill patients for it, so the funding for that care will have to come "from the limited margin that hospitals generate to reinvest in our people and our programs and our facilities."

The reduced monoclonal antibody shipments to states this week may also affect health systems and patients. Zaas' health system has been providing those drugs to patients and even turned an old restaurant in a shopping mall into a COVID-19 infusion center. It's unclear yet what the supply or cost of these drugs will be going forward, he says, though there's also uncertainty about whether they'll be effective against future variants.

The trade group representing Zaas' health system — America's Essential Hospitals — says these worries are being felt at hospitals that serve low-income and uninsured patients across the country.

"We are imploring Congress — and reaching out to the administration as well — to try to get at least some targeted financial relief to safety net institutions in the coming months," says Beth Feldpush, senior vice president for policy and advocacy for America's Essential Hospitals.

She's worried, not just about whether hospitals will be reimbursed for caring for uninsured patients, but about whether there will be enough workers to provide that care. Health care workers are burned out by the pandemic, and many are leaving the field. Federal funding to help hospitals find, train and retain staff is drying up as well, she says, which is "really going to squeeze essential hospitals a lot over the coming months."

Lost access to free care could fuel future outbreaks

As federal funds begin to dwindle, the strain on hospitals' budgets and the reduced access to COVID-19 prevention and care for uninsured patients could have ripple effects.

There are 28 million uninsured people in the United States. If someone who's uninsured is afraid to get tested for the coronavirus because of the risk of getting billed for it, the person might just not get tested when sick.

The person might also keep going to work in public-facing jobs, like serving food or driving an Uber. Zinzi Bailey, an epidemiologist at the University of Miami Miller School of Medicine, says all those hidden cases can drive more spread, with "bigger surges, different variants."

"And we do not have this thing under control," she says.

Nearly 700 people are still dying from COVID-19 every day on average across the country.

"We're going back to common spaces. We're going to be interacting. There's no way to really divorce ourselves from people who may be uninsured," Bailey says. Masks are also coming off, which makes it easier for the coronavirus to spread.

At the same time, the country might not notice if and when new surges begin — surveillance to detect and track new variants is also on the list of pandemic-fighting tools that are in danger of being cut.

"If we aren't doing surveillance — either because we're hoping for an end to the pandemic or because the money runs out and health departments and other institutions can't afford to do it — then we are going to be caught unawares next time," says Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security.

Already, at-home tests have made case counts unreliable measures of the true amount of virus in a community, and wastewater surveillance doesn't cover the country evenly.

Boom-and-bust health funding continues

Watson is discouraged but profoundly unsurprised that lawmakers seem unwilling or unable to put more funding toward the pandemic.

"This looks like every other public health emergency that we've faced in the last 20 years," she says. "Congress seems to get very fatigued of funding the emergency response, and so after people perceive that the acute emergency is over, they're very quick not only to reduce funding but then to also really devalue the programs that are intended to prepare for the next emergency."

Groups like the nonprofit Trust for America's Health and the National Association of County and City Health Officials have enumerated the folly of this boom-and-bust approach to public health funding.

But the cycle continues. Additional pandemic funding seems stalled in Congress.

One reason for the standoff is that Republican lawmakers have argued that they need a more detailed accounting of where previous COVID-19 funding has gone. At the White House's first COVID-19 news conference in weeks, last Wednesday, health officials retorted that they've provided plenty of detail, and they even brought 385 pages of documents provided to members of Congress to prove it.

Gregg Gonsalves, an epidemiologist at Yale University who studies public responses to infectious disease, notes that the federal government's messaging about how the pandemic is easing may be in part to blame for the impasse.

"I don't understand how they can't see the cognitive dissonance of the downplaying of the pandemic and then the need to get more money from Congress," he says. "Either it's a crisis and you need more money, or it's not a crisis and you don't need more money."

He says even if cases are low, the country shouldn't let up on surveillance, free tests and other efforts to keep the virus at bay. "You hope for the best and you plan for the worst," he says. "You don't just hope for the best, which is the national policy right now."

In his South Carolina hospital network right now, Zaas says, there are only 43 COVID-19 patients across all their hospitals, but he's still feeling nervous about what's next.

"Even though COVID numbers are dropping around the country, none of us know what's going to happen over the next six months," he says. "I think all of us are worrying about an additional wave."

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