Long COVID is linked to higher direct healthcare costs in U.S. adults

The World Health Organization defines long COVID as the continuation or development of new symptoms at least three months after an initial SARS-CoV-2 infection, lasting for at least two months with no alternative explanation [1]. Long COVID has become an emerging issue with substantial clinical and humanistic burden because of wide-ranging symptoms such as fatigue, dyspnea, cough, headache, chest and joint pains, smell and taste disturbances, cognitive and mental impairments, and gastrointestinal and cardiac issues [2]. Additionally, long COVID has been linked to the onset or exacerbation of other chronic conditions such as migraines, lung disease, autoimmune disease, and chronic kidney disease [2].

Globally, an estimated 65 million individuals are affected by long COVID [3]. In the United States (US), prevalence estimates range from as low as 1.3% in children [4] to as high as 32.2% among adults, ref. [5] depending on population and symptom definitions. Nationwide, among non-institutionalized civilian adults (i.e., individuals living in households and community settings rather than in institutions such as nursing homes, prisons, or long-term care facilities), the prevalence of long COVID has been estimated at 7% [6].

Beyond the high prevalence and clinical burden, long COVID can lead to the financial hardship of individuals and society through higher direct and indirect medical expenditures and diminished productivity. Several studies report significant economic impacts within the United States and internationally. A computational simulation model study revealed that the direct medical expenditures due to COVID may vary by age, sex, and long COVID duration, with an average total expenditure for an adult male being USD 9906 with an uncertainty range of USD 2637–USD 27,386 [7]. Furthermore, the same study reported that 95% (USD 9432) of these costs were due to productivity losses. David Cutler estimated the economic costs of long COVID in the United States (US) at USD 3.7 trillion, comprising lost quality of life (~USD 2.2 trillion), cost of lost earning (USD 997 billion), and spending on healthcare (USD 528 billion with USD 11,189 per capita costs (~USD 1566 direct healthcare expenditures) [8]. An analysis of the Census Household Pulse Survey shows that U.S. working-age adults lost an estimated USD 211 billion in earnings to long COVID in 2022, rising to USD 218 billion in 2023 [9]. In terms of direct healthcare expenditures, a retrospective study of insurance claims data found that those with long COVID had two times higher 6-month expenditures (USD 1182.8 vs. USD 2473.6) compared to the pre-diagnosis period [10]. Using Colorado state's All-Payer Claims Database, researchers observed that adults with long COVID visited outpatient clinics and specialists more often in the year after diagnosis [11]. This uptick in service use implies considerably higher direct healthcare expenditures.

A population-based longitudinal Electronic Health Records study from the United Kingdom reported persistent higher expenditures even two years after long COVID diagnosis [12]. In this study, those with long COVID had nearly 1.5–2.0 times as much as expenditures as in age- and comorbidity-matched individuals during the pandemic [12]. A study from Israel reported that among individuals without long COVID, healthcare expenditures decreased from New Israeli Shekel-(NIS) 1400 to NIS 1021 four months post-infection. In contrast, expenditures among those with long COVID increased from NIS 2435 to NIS 2810 [13].

Although existing research from the US and elsewhere has highlighted the economic burden of long COVID, nation-wide representative studies that have examined the association of long COVID with healthcare expenditures at the individual level in the US is sparse. Such studies are critical to gain a comprehensive understanding of the economic burden of long COVID. Therefore, the objective of this study was to estimate the excess total, payer, and out-of-pocket direct healthcare expenditures associated with long COVID among adults in the U.S. The individual-level expenditure estimations are essential for guiding policymakers, payers, and employers in developing targeted strategies to mitigate the financial impact of long COVID on patients and the healthcare system.

Among US adults aged 18 or older (Table 1), 48.7% were females. NHW comprised the largest group (60.8%), while Hispanic and non-Hispanic Black groups represented 17.6% and 12.1%, respectively. Nearly one-third (35.8%) had a college degree, with 45.2% reporting were high income (≥400% FPL). Over one-third (36.6%) of participants reported multimorbidity (two or more chronic conditions). An overwhelming majority of adults (83.5%) received the primary series COVID vaccination.

Overall, 7.0% of US adults experienced long COVID, 43.7% had acute COVID, and 49.3% did not report any COVID (Table 2). A higher percentage of females (8.7% vs. 5.2%) than males reported long COVID. Long COVID prevalence was highest among those aged 45–54 and 55–64 (9.2% each) compared to 6.1% in the 18–44 group and 5.8% in those aged >65 years. Racial and ethnic differences were evident: non-Hispanic White individuals had the highest prevalence of long COVID (7.9%), followed by Hispanic (6.7%) and non-Hispanic Black individuals (4.5%).

Table 2 also displays the average total, payer, and out-of-pocket healthcare expenditures by COVID categories. Overall, the average total expenditures were USD 7673 (standard error (SE) = 190.3), including payer expenditures (USD 6605, SE = 176.3) and out-of-pocket spending (USD 1068, SE = 41.3). Adults with long COVID had notably higher total (USD 11,305 vs. USD 7162), payer (USD 9983 vs. USD 6097), and out-of-pocket (USD 1322 vs. USD 1065) expenditures compared to those without COVID.

Table 3 presents the findings from the multivariable GLM with gamma distribution and log link on total, payer, and out-of-pocket expenditures. Adults with long COVID had higher total and payer expenditures compared to those without COVID. When translated into percentages by exponentiating the regression coefficients, we observed that adults with COVID had 1.54 and 1.58 times greater total and payer expenditures as those of adults without COVID. After adjustment, adults with long COVID had the highest total expenditures. The adjusted mean was USD 11,641 (95% CI USD 9279–USD 14,004) for long COVID, USD 8361 (7656–9066) for acute COVID, and USD 7543 (6984–8103) for no COVID. When compared to no COVID, the excess total expenditures were +USD 4098 (95% CI USD 1619–USD 6578) for long COVID and +USD 818 (−USD 93 to USD 1728) for acute COVID. Most of the long COVID excess was borne by third-party payers (+USD 3705, 1442–5968), while out-of-pocket differences were small and not statistically significant (+USD 236, −95 to 566).

However, we did not observe a statistically significant difference in out-of-pocket expenditures by COVID categories.

To evaluate whether results were driven by multimorbidity, we conducted analyses stratified by multimorbidity (≥2 vs. 0–1 chronic conditions). For each outcome (total, third-party, OOP), we fit survey-weighted two-part models (logit for any spending; gamma with log link for positive spending) with the same covariates as the primary analysis and reported average marginal effects (dy/dx) for long COVID and acute COVID versus no COVID (interpreted as excess USD ).

Our results indicated that compared to no COVID, excess total expenditures for long COVID were USD 3737 (SE USD 1234; p < 0.01) among those with multimorbidity and USD 2603 (SE USD 1112; p < 0.05) among those no multimorbidity. Long COVID excess third-party spending was USD 4192 (SE USD 1356; p < 0.001) for the multimorbidity group and USD 1216 (SE USD 989; p < 0.05) for the no multimorbidity group. We did not observe statistically significant differences in OOP expenditures. Thus, our main findings are not explained by comorbidity burden alone. Please note that because two-part models are nonlinear and were fit independently, the model-based contrasts (excess USD) are not algebraically constrained to satisfy third-party + OOP = total.

Overall, about 1 in 14 U.S. adults reported long COVID, highlighting the substantial population affected by ongoing symptoms. The estimated long COVID prevalence of 7.0% among US adults found in our study closely aligns with recent national data on non-institutionalized civilians. For example, the Census Household Pulse Survey found that the prevalence of long COVID among non-institutionalized adults was 7.5% during 7–19 June 2023 [19]. Similarly, an analysis of 2022 National Health Interview Survey (NHIS) data estimated that 6.9% of adults had experienced long COVID [20]. This similarity may reflect that both the MEPS and national surveys referenced restricted analyses to non-institutionalized, civilian populations. As such, our estimate is consistent with others, capturing the same population scope, though prevalence in institutionalized settings remains less well-characterized. Because the MEPS relies on self-reported COVID history, the proportion classified as 'no COVID' may be overestimated. CDC seroprevalence data indicate that by July–September 2022, 70.3% of U.S. adults had evidence of prior infection (22.6% infection-induced only, 47.7% hybrid immunity), which suggests that underreporting is likely [21].

In our study, adults with long COVID had higher healthcare expenditures compared to those without COVID, consistent with other studies reported in the literature [22]. Expenditures among individuals with acute COVID generally fell between those with long COVID and those with no COVID. Given the broad and persistent symptomatology of long COVID, affected individuals utilize a wide range of healthcare services including general practitioner visits, outpatient services, and emergency department visits [11]. Although COVID-19 was initially recognized as a respiratory illness, SARS-CoV-2 is now understood to affect multiple organ systems. This multisystem involvement is thought to be primarily mediated by immune activation and persistent inflammation rather than direct viral invasion [3]. In particular, endothelial dysfunction has emerged as a hallmark of long COVID [3]. Additionally, alterations in the size and stiffness of blood cells have been identified in individuals with long COVID, potentially impairing oxygen delivery and perpetuating organ dysfunction [3]. These biological disruptions may help explain the progression of existing chronic illnesses and the emergence of new conditions, many of which are not fully captured in administrative data or clinical records. Furthermore, these findings underscore that persistent symptoms, the worsening of existing chronic conditions, and the new onset of chronic conditions due to long COVID require ongoing healthcare needs long after the acute infection is resolved.

Research has consistently shown that individuals who develop long COVID often have more underlying chronic conditions than those who do not. Our study supports these findings, as individuals with multiple chronic conditions were more likely to experience long COVID. For instance, research has reported that long COVID patients had a higher Charlson comorbidity index (1.2 vs. 0.9), indicating a higher baseline health burden [23]. Although multimorbidity was more prevalent among individuals with long COVID, our findings suggest that it does not fully explain the observed differences in healthcare expenditures across groups. Chronic conditions likely compound long COVID's impact, as managing long COVID in addition to multiple chronic illnesses may lead to frequent appointments, medication adjustments, and potential complications. It can be challenging to disentangle long COVID-specific costs from overall healthcare costs in such cases; however, our study revealed that individuals with comorbidities had a higher percentage of total healthcare expenditures compared to those without comorbidities. Long COVID patients may need to consult multiple specialists due to various chronic conditions, which can lead to prescribing several medications, increasing the risk of fragmented care and polypharmacy [24]. Multidisciplinary clinics streamline care delivery and can mitigate the cost effects of long COVID. The Agency for Healthcare Research and Quality has awarded grants to support such clinics, aiming to provide comprehensive, coordinated, and person-centered care for people with long COVID, particularly in communities disproportionally affects by the impacts of long COVID [25].

In our analysis, we did not detect a statistically significant difference in annual out-of-pocket medical spending between individuals with long COVID and those without COVID. Despite significantly higher total and payer expenditures among adults with long COVID, this finding suggests that much of the financial burden is absorbed by third-party payers—including private and public insurers—rather than falling directly on patients. This apparent discrepancy arises because out-of-pocket expenditures represent a relatively small and highly variable component of total healthcare costs. In the U.S., most COVID-19-related expenditures are covered by insurance, which concentrates cost differences within payer spending rather than patient OOP contributions. These results align with the structure of U.S. health insurance systems, where deductibles and copayments typically represent only a fraction of total costs. However, out-of-pocket expenses represent just one facet of the overall financial burden. As highlighted in the introduction, indirect costs—such as lost productivity, reduced work capacity, and caregiving demands—are substantial [9]. To fully capture the economic impact of long COVID, future research should incorporate both direct and indirect cost measures and examine how evolving care pathways and treatment approaches influence long-term patient financial responsibilities.

Our study benefits from a large, nationally representative sample of U.S. adults and the detailed expenditure information provided by the MEPS. This allowed for a comprehensive understanding of the economic burden of long COVID on both individuals and third-party payers. Furthermore, the study adjusts for a wide range of factors that may influence healthcare expenditures, such as demographic factors, socioeconomic status, and lifestyle factors. However, several limitations should be considered. The MEPS collects self-reported data on health conditions, socioeconomic factors, and lifestyle behaviors, which may be subject to recall bias or reporting inaccuracies. As an observational study with a cross-sectional design, causality cannot be established. Because temporality between long COVID onset and healthcare utilization cannot be determined, higher expenditures may partly reflect pre-existing morbidity or healthcare needs unrelated to long COVID itself. The use of data from only one calendar year (2022) also limits the ability to assess changes in long COVID-related expenditures over time; future studies should incorporate multi-year analyses to evaluate trends. Because we used the annual consolidated file, we could not assess the within-year timing of COVID onset, symptoms, or expenditures captured at the quarterly level; COVID status capture may vary by quarter. This limits inferences on temporality and may introduce misclassification. Despite extensive covariate adjustment, unmeasured confounding remains possible, as variables such as COVID severity, pre-infection healthcare utilization, vaccination timing, and chronic disease severity and duration were unavailable. Additionally, the classification of long COVID relied on self-reporting, which may lead to misclassification; future research should validate diagnoses using clinical records or standardized symptom inventories. Furthermore, the MEPS does not collect information on specific symptom clusters (e.g., fatigue, cognitive dysfunction, respiratory issues due to COVID), which limits our ability to assess whether different long COVID phenotypes are associated with varying healthcare cost burdens. Because the MEPS includes only non-institutionalized survivors, we could not capture the highest-severity outcomes such as institutionalization or death, which may lead to underestimation of the true economic burden. Finally, our analysis was limited to direct healthcare expenditures and did not include indirect costs such as absenteeism, lost productivity, or societal costs. As such, our estimates reflect a healthcare system and payer perspective rather than the total economic burden of long COVID.

Adults with long COVID incurred 1.5 times higher healthcare expenditures compared to those without COVID, with most of the burden on insurers and payers. These findings underscore the substantial and persistent impact of long COVID on the U.S. healthcare system. Policymakers, payers, and healthcare providers should prepare for the long-term resource implications, particularly for populations with multimorbidity or other social vulnerabilities. Proactive investments in coordinated care models, such as multidisciplinary clinics and patient-centered medical homes, are essential to managing both the clinical complexity and economic costs associated with long COVID.