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Long COVID continues to hinder the health of millions of U.S. workers and will be a factor in rising employer health care costs. By taking a proactive approach to benefit plan design as well as the management of chronic and complex health conditions, employers and benefit plan sponsors can help workers struggling with long COVID while containing costs.

Nearly three years after the COVID-19 pandemic first disrupted our lives, its impacts are showing no signs of letting up. Public health officials are now grappling with a new phase of the pandemic called long COVID, which refers to lingering symptoms of the infection that can last for weeks, months or even years. Faced with this challenge and rising health care spending, employers and plan sponsors must figure out how to navigate this new normal by approaching their benefit plan designs proactively. Doing so can improve health plan participant outcomes and the bottom line.

Since the Centers for Disease Control and Prevention (CDC) began keeping track in January 2020, close to 100 million cases of COVID-19 have been reported in the United States. The extremely contagious virus has killed close to 7 million people around the world, including more than one million in the U.S.

First discovered in Wuhan, China in December 2019, COVID-19 is most likely to attack the respiratory system, causing some people to have mild symptoms and others to become severely ill. The virus is also not finished evolving: CDC is tracking 16 subvariants of omicron, the most recent variant of SARS-CoV-2 (the virus that causes COVID-19). Some of these subvariants appear to be among the most immune-evasive to date, and brand-new variants are expected to continue to emerge.

If that isn’t enough, researchers, doctors and public health officials are now grappling with long or long-haul COVID, which some are describing as our “next national health disaster” or as the “pandemic after the pandemic.” According to CDC, long COVID affects nearly 20% of people who had a past COVID-19 infection, even if they only had a mild case.

Yet the physical health of people impacted by long COVID isn’t the only consequence of the condition. It’s also impacting people’s ability to work and make a living—and forcing employers and plan sponsors to proactively overhaul their benefits plan designs through the lens of long COVID at a time when health care spending is already rising.

What Is Long COVID?

The CDC defines long COVID as COVID-19 symptoms lasting more than four weeks after a person’s initial diagnosis. Long COVID goes by other names, including post-acute sequelae of SARS-CoV-2-infection and post-COVID conditions (PCCs). A Mayo Clinic study showed that the average age of people with long COVID is 45—younger than those who suffer from severe acute infections. The study also found that the condition affects more women than men.

Like other poorly understood chronic illnesses that can occur after an infection (such as chronic fatigue syndrome), long COVID can affect nearly every organ system in the body. It can also create new or worsen chronic health problems, such as heart and kidney disease, diabetes, hematologic (blood) disorders, neurologic conditions and mental health disorders.

Symptoms

More than 200 symptoms are associated with long COVID. They don’t affect everyone the same way and can even come and go. The symptoms are also relatively vague and common—often attributable to any number of diseases and conditions.

The most frequently reported symptom of long COVID is fatigue that interferes with a person’s daily life. Another is brain fog, which is described as trouble with thinking, including problems with focus, memory and word recollection. Researchers believe brain fog may be the result of changes in brain structure caused by COVID-19 infection. One study found that up to 40% of people with mild to moderate cases experienced cognitive decline.

Following are other long COVID symptoms.

• A nagging cough
• Chest pain
• Diarrhea
• Dizziness
• Headaches
• Heart palpitations
• Joint or muscle pain
• Loss of taste and smell
• Mood changes
• Pins-and-needles feeling
• Rashes
• Shortness of breath
• Stomach pain
• Trouble sleeping

In the past year, doctors have also reported seeing more gastrointestinal problems in people with long COVID. One analysis found gastrointestinal symptoms in 22% of people with the condition. These symptoms range from loss of appetite and taste to abdominal pain and irritable bowel syndrome.

Treating Long COVID

The science behind what causes long COVID is still murky. Research has found that some of the cells used to create immunity after an infection may malfunction instead. Scientists are also exploring other possible causes, including that the virus sticks around in some parts of the body after acute infection, that it triggers a chronic inflammatory response in certain people or that the immune system starts attacking itself.

Because there isn’t a clear cause—and no diagnostic test currently exists—providers typically align treatment efforts with managing a person’s symptoms. This may include focusing on sleep and diet and recommending frequent breaks from prolonged physical activities for people struggling with fatigue and shortness of breath.

The good news is that as long COVID becomes increasingly a part of our country’s lexicon, primary care providers become better equipped to recognize the condition and correctly diagnose it. In fact, around 70 hospitals and health systems have created clinics devoted to diagnosing and treating long COVID.

One of the first recommendations from providers to patients with long COVID is to take care of themselves—by drinking plenty of water and eating and sleeping well. Patients are also advised to seek care early since research shows that those who receive treatment earlier experience better outcomes, like a faster and more complete recovery.

Ideally, treatment starts with an empathetic primary care provider who can help validate the patient’s experience, diagnose the condition, begin treating symptoms and make a referral to a specialist program, such as one for physical therapy rehabilitation. Working with a team of occupational and physical therapists can help patients establish a proper rate of recovery and appropriate recovery activities.

Establishing continuity of care within an integrated health system can help patients connect with the right team of providers and get them started with treatment quickly. This is opposed to fragmented care, or patients hopping from one doctor to another when they already may be exhausted—not to mention racking up unnecessary appointments and tests that can add up to wasted dollars.

Health Care Spending on the Rise

As with so many aspects of life in the U.S., the COVID-19 pandemic had a dramatic impact on the nation’s health care sector in 2020, driving a 9.7% growth in total national health care expenditures to $4.1 trillion. Rising health care spending is only expected to continue. By 2028, health care spending is expected to reach more than $6 trillion.

People with long COVID and their employers are feeling these effects, with one study estimating that a person with the condition spends nearly $9,500 on treatment in the first six months after a diagnosis. That means employers are spending 26% more for their employees with this condition than they did for their employees with diabetes in the first half of 2022. Some of these costs may be coming from misdiagnoses, fragmented care and providers not recognizing long COVID when they see it.

Aside from increasing health care spending, long COVID is impacting productivity. Researchers estimate that two to four million working-age persons in the U.S. are out of the workforce due to long COVID. One survey found that among those with long COVID who are still working, 51% work fewer hours.

A recent analysis of workers’ compensation claims in New York found that during the first two years of the pandemic, about 71% of people who received workers’ compensation benefits because of long COVID either required medical treatment or were unable to work for six months or longer. The analysis also found that more than a year after contracting the virus, 18% of long COVID patients had still not returned to work and three-fourths of them were younger than 60.

This reduction in labor directly correlates to earning losses. If two million people are out of the workforce because of long COVID, for example, roughly $100 billion is lost in annual income. Researchers also say that long COVID may be partly to blame for the recent inflation surge in the U.S.

To help mitigate some of these effects and help people with the condition get treatment faster, Congress provided more than $1 billion to the National Institutes of Health to study long COVID. One of the ways this funding is taking shape is through the RECOVER Initiative, a large-scale study of the long-term effects of COVID-19 on people of all races and ethnicities, genders, ages and locations.

Some of this money is also helping fund the CDC Track PCC Initiative, which looks at how long COVID affects people across all age groups and populations, including those who are underserved and experience disparities, such as Hispanics, Native Americans, children and people with special needs.

Disability Protection

In July 2021, the Department of Health and Human Services (HHS) announced that Americans with long COVID could qualify for disability protections under the Americans with Disabilities Act (ADA).

Disability under ADA qualifies an employee to receive reasonable accommodations, such as paid leave, a restructured job or reassignment to another position, shorter shifts, a place to sit during work hours or a service dog to help with stability. Reasonable accommodations can also include a modified break room or workspace layout.

While these are all steps in the right direction, there’s still plenty of confusion among employees and employers alike on what constitutes long COVID as a disability under the ADA. In general, long COVID is considered a disability under the ADA when someone experiences prolonged symptoms that interfere with their ability to perform the essential functions of their job. A recent International Foundation blog post provides more information about the interactive process that employers should engage in when evaluating a request for an ADA accommodation related to long COVID.

Benefit Plan Strategies for Addressing Long COVID

Faced with rising health care spend, employers and plan sponsors must find innovative solutions to manage costs while providing access to quality care to all workers. One way they can do this is by taking a proactive approach to chronic and complex health care conditions.

Around 60% of adults in the U.S. have a chronic disease, and 40% have two or more. Conditions like heart disease, cancer and diabetes are the leading causes of death and disability in the U.S. They’re also the leading drivers of health care costs. Typically, just 1% of a plan’s participants can drive 40% of its health care spending in any given year.

Strategies may include increasing access to quality providers by evaluating current network providers, expanding vended solutions that focus on access to high-quality care or contracting with a center of excellence. Focusing on areas of high spend or where costs are increasing rapidly within the medical plan—regardless of whether they are related to long COVID—can help employers lower their health care spend, increase their workforce productivity and, most importantly, improve outcomes for their employees.

Taking a proactive approach to benefit design can also help individuals with long COVID. That means ensuring that the medical plan has appropriate coverage for the symptoms and conditions associated with the disease. Appropriate coverage may include services already in the plan, like organ transplant and mental health services. Employers may need to evaluate the ease of access to imaging and/or lab services or add additional disease management services, similar to diabetes management but for gastrointestinal diseases or chronic fatigue. They may want to consider creating a more comprehensive employee assistance program (EAP) that expands services beyond mental health into areas of financial well-being, work-life balance or will/estate planning. Employers should review policies around paid sick leave to see whether they provide qualified flexibility in work hours or workdays. Organizations also could consider providing access to digital programs that focus on services for people with long COVID. Capabilities may include symptom tracking, self-assessment tools and educational content.

Improving Health Outcomes—And Bottom Lines

As COVID-19 continues to evolve, so will research surrounding its long-term effects. That’s why employers should consider programs that will help take care of employees suffering from this condition. Doing so not only improves their health outcomes but should also improve employers’ bottom lines.

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Cheryl Nienhuis, CEBS, PHR, is director of the Mayo Clinic Complex Care Program. She has more than 20 years of benefit experience, including benefits leadership at Mayo Clinic. She now helps employers manage health care costs while providing high-value health care benefits to employees. Nienhuis holds an M.B.A. degree in marketing and a health care management degree from Dallas Baptist University.

Augustine Chavez, M.D., is a consultant and the associate chair of practice in the department of family medicine at Mayo Clinic Arizona and assistant professor at the Mayo Clinic Alix School of Medicine. Prior to joining Mayo Clinic in 2015, he was medical director of a large federally qualified health center in New Mexico. Chavez’s clinical, education and research interests center on health equity and population health. He holds degrees in history and biology from the University of New Mexico and holds an M.D. degree from the  University of New Mexico School of Medicine.