With more than 51 million Americans filing for unemployment since mid-March, the financial fallout of the Covid-19 pandemic has made managing chronic disease an afterthought for some, and an impossibility for others.

Lacking adequate resources, many are struggling to maintain their medical regimens, which often involve produce-rich diets and regular purchases of prescription medication.

“We definitely are seeing a number of patients who are really just barely getting by,” says Dr. Mary Herbert, the clinical director of the Birmingham Free Clinic in Pittsburgh, Pennsylvania.

Herbert treats patients with chronic diseases, such as hypertension, diabetes, and heart disease. She says many of her patients are forgoing care to attend to more immediate needs, such as paying the rent or feeding their families. Others have been unable to pick up their prescriptions because they can’t afford the cost of transportation.

On this episode of the podcast, we speak with Dr. Herbert and other healthcare providers about how the financial consequences of the Covid-19 pandemic are affecting patients’ ability to manage their chronic conditions.

Grace Medical Home received a Continuity in Care grant from a joint initiative between Direct Relief, BD, and the National Association for Free and Charitable Clinics. Since 2008, Direct Relief has provided $373.8 million in medical support to 863 free and charitable clinics, and has also provided more than $2 million in emergency grants and funding focused on chronic disease management.

Transcript:

For Dr. Kirsten Carter’s patients, the last thing on their mind is managing their chronic condition.

“I’m asking them about healthy food. They don’t have food period, let alone healthy options.”

Carter is an internal medicine physician at Grace Medical Home in Orange County Florida. The clinic offers medical services for free to uninsured individuals.

“They are the uninsured of orange County, Florida. So what that means is they either don’t qualify for Medicare Medicaid, they don’t have positions that offer insurance for whatever reason, they don’t qualify for the affordable healthcare act or can’t afford it. And that includes undocumented.

Carter’s patients are facing some of the worst financial consequences of the COVID-19 pandemic.

Many work in Florida’s service industry, which was gutted overnight by the state’s stay at home order. With theme parks closed and businesses shuttered, these employees found themselves without work–and, for some-without unemployment insurance.

Many of Carter’s patients are self-employed–housekeepers, landscapers. Or, independent contractors hired out by hotels and amusement parks to repair appliances or provide cleaning services. Since these workers aren’t required to pay into unemployment, they’re on their own should they lose their job.

While federal unemployment benefits have been extended to independent workers under the CARES Act, navigating the application process can be prohibitive particularly for those whose first language isn’t English or who aren’t technologically connected.

For the undocumented, protections are especially limited.

“A lot of patients have been evicted from their homes because the laws in FL that put a moratorium on evictions do not apply to undocumented. And they’re not eligible for unemployment.”

Since unemployment rates skyrocketed, Carter has watched her chronic disease patients slip into poor health.

Some can’t afford their medications anymore.

“I have a patient who I just saw yesterday that has, um, bad anemia and she wasn’t taking her medication because she didn’t have the $2 to take it.

Others are forgoing care to attend to more immediate needs.

One of her patients is facing eviction after losing her job in the hospitality industry.

When she came in for a recent checkup, her blood pressure had become uncontrolled.

“She was so anxious about just trying to find housing for their family and what was going to happen to them that the last thing she was doing was remembering to take her medical regimen.”

And others can’t make it to the pharmacy every month to pick up their prescription.

“Before, when they were working, they could either take the bus, which costs money, Uber, which costs money, or get a friend to drive them. Now their friend has lost their car or can’t afford gas…So those transportation barriers have gone up significantly.”

To help, staff at Grace Medical Home have been hand-delivering medications to people’s homes.

They’ll often drop off personal hygiene items and groceries, too.

Many of Carter’s patients are food insecure, making it difficult to choose healthy options. Since diet is a hallmark of chronic disease management, the clinic regularly delivers fruits and veggies to patients’ doorsteps.

Since March, staff have passed out over 160 boxes of food to patients experiencing food insecurity.

But Grace Medical Home isn’t the only safety net provider doing these sorts of deliveries during the pandemic.

At the Birmingham Free Clinic in Pittsburgh, Pennsylvania, staff are going into neighborhoods to bring patients medications, food, and cash assistance for rent.

“We definitely saw or are seeing a number of patients who, you know, are really just barely getting by.”

Dr. Mary Herbert is the Clinical Director of the Birmingham Free Clinic. She says many patients have lost their jobs, and–like Carter’s–are struggling to maintain their housing.

“You know, in our state, the governor issued a moratorium on evictions, but some of our patients just, they didn’t even know the first thing about how to begin to advocate for themselves. And they were getting pressure from their landlords that, Hey, your rent is due. And, also thinking about, okay, maybe I can pay my rent this month, but even if I don’t pay it for the next two months, because my landlord gives me a break, I’m still unemployed. And now I’m just racking up this huge rent bill.”

These kinds of financial stressors are a double whammy for patients with chronic disease.

Not only does it make it difficult to pay for their medication or afford the transportation to pick it up, long term stress also leads to conditions that exacerbate, and may even cause, chronic disease.

It’s widely accepted that stress can lead to depression, anxiety, and weight gain—all factors that make it harder to control a chronic condition like high blood pressure or diabetes.

But recently, scientists have shown that experiencing high levels of stress over an extended period of time may actually cause chronic disease.

According to a study published in Nature Medicine, stress causes an overproduction of white blood cells, which stick to the artery walls and build up as plaque causing heart disease and increasing the risk of heart attacks.

And, a limited body of research, suggests a link between stress and insulin resistance, a precursor to Type 2 diabetes.

But Dr. Herbert says it’s not all bad for her patients with chronic disease.

“I think some of them have actually done a better job of managing their disease state at home.”

The need to limit in-person visits has encouraged the clinic to shift its approach to chronic disease management.

“Since patients weren’t coming into us as regularly, we wanted to make sure everybody was monitoring at home.”

The clinic has gifted patients with monitoring devices to check their blood pressure or measure their glucose levels. And, they’re teaching patients how to interpret those values so they can determine for themselves whether their chronic disease is under control.

“The irony is, I think some of those patients, this model that we had pretty quickly transitioned to actually works better for them.”

As patients’ circumstances change, so have the ways in which Dr. Herbert and her staff provide care.

If her patients face a choice between putting food on the table and affording their monthly medication, what can she do to ensure they’re able to do both?

“It pushes us to continue to look at each patient’s own individual capacity,” she says, “That’s really what individualized medicine is about.”

This transcript has been edited for clarity and concision.