COVID or a summer cold? Without free tests, many won’t know.

The United States is experiencing a bump in coronavirus transmission for the first time since the public health emergency ended in May, exposing the challenges of avoiding the virus when free testing is no longer widely accessible.

The Biden administration stopped mailing test kits to households in June. The ones Americans stockpiled over the last year and a half are expiring. Major insurers no longer pay for over-the-counter tests once the requirement to do so ended with the emergency declaration.

As a result, those who still factor COVID into their daily lives are weighing whether it’s worth roughly $12 to test for every sniffle and scratchy throat and every visit to grandma. The costs quickly add up for larger families and for people who’ve contracted COVID intent on protecting others by following federal guidelines to test repeatedly to end isolation and masking.

This new landscape for testing presents one of the starkest examples of living in a society that treats COVID as any other endemic respiratory virus. In a nation with widespread immunity, most COVID infections are mild with a greater danger to the elderly and severely immunocompromised.

“We are going to continue to see people hospitalized for COVID for illnesses that could have been prevented had testing been freely and widely available,” said William Schaffner, a medical professor who specializes in infectious diseases at Vanderbilt University Medical Center.

Coronavirus is increasing by multiple measures - but it’s not causing alarm among public health officials.

The Centers for Disease Control and Prevention recorded 9,000 COVID-19 hospital admissions in the week ending July 29, a 12.5 percent increase from the week before. But that’s far below the nearly 45,000 admissions recorded the same week a year ago. The percentage of emergency department patients diagnosed with COVID-19 has risen gradually in July but is less than a fifth of where it was a year ago. Experts believe there’s likely an uptick in mild coronavirus cases outside of the health-care system as well.

“It’s not increasing at such a rate that’s alarming and nothing strange is beginning to happen and making people sicker,” said Lori T. Freeman, executive director of National Association of County and City Health Officials.

Fluctuations in COVID activity are expected, especially during the summer - a time for vacation and big gatherings like weddings and conferences.

[Risk of loss of smell from COVID has plummeted since 2020]

Some people, regardless of their personal risk level, want to know if symptoms indistinguishable from a cold or allergies are actually COVID-related so they can avoid infecting the vulnerable.

In mid-July, Mark Camenzind tested positive using his last over-the-counter test in his stockpile after hanging out with a friend who contracted the virus. He had a vacation to the Pacific Northwest looming but wanted to test negative twice, 48 hours apart, as recommended by the Centers for Disease Control and Prevention, before going maskless.

But finding free tests in Lawrence, Kan., was challenging and his insurer no longer reimbursed retail purchases.

After posting on a local Reddit forum, Camenzind found a pharmacy that conducted free tests on-site. He tested negative and bought his second test at Walmart.

“I think it’s important for the community to protect each other’s health. I’m pretty spooked by long COVID, and I wouldn’t want to wish that on anyone,” said Camenzind, 25. Still, “I don’t want to end up at the point I want tests and it’s costing me hundreds of dollars.”

With some sleuthing, Americans can still find free tests in parts of the country at places like libraries and health clinics.

The program mailing free tests to Americans and the requirement that insurers pay for over-the-counter tests ended with the public health emergency. And if you want to test to find out if you are positive or still contagious, out-of-pocket costs can quickly add up.

Since the emergency ended, the Biden administration has been distributing an average of 4 million over-the-counter tests a week to institutions including long-term care facilities, community health centers and food banks, according to the Administration for Strategic Preparedness and Response at the U.S. Department of Health and Human Services. Federal officials are also providing tests to local governments, according to the National Association of County and City Health Officials.

The CDC has a website showing where people without insurance can get free coronavirus testing, but the network of sites has shrunk since the end of the health emergency.

The Big Cities Health Coalition says at least 20 of its 35 member cities have some sort of free take-home test distribution program and those that do not cite lower demand or availability in clinical settings. Los Angeles County has been distributing 250,000 kits a week, mostly to shelters and community organizations that serve low-income people. Officials in Tucson distributed 800 rapid tests at a recent back-to-school event.

Still, health officials continue to emphasize vaccination to bolster population immunity in lieu of controlling transmission. Federal officials are preparing a fall booster campaign using a new formula tailored to the XBB variants that have been dominant throughout the year. Pfizer told investors it expects to start offering its updated booster in September, pending regulatory approval.

Some medical experts say the time for widespread testing has passed.

Shira Doron, chief infection control officer for Tufts Medicine in Massachusetts, said the better approach for controlling COVID transmission is to encourage people to stay at home until they are fever-free, rather than testing to end isolation.

“We can be contagious for flu or RSV for a week, but we have always said you can go back to work or school when you are fever-free. Yes, people can still be contagious, but so are asymptomatic people walking around and transmission is inevitable,” Doron said. “Most people don’t need to know what virus they have and don’t need to be buying tests all the time.”

Those who would benefit from regular testing, Doron added, are those who are at higher risk for hospitalization and would benefit from antivirals such as Paxlovid in the early days of symptoms to halt progression to severe disease.

Susan Grammerstorf, a 65-year-old nurse in Virginia Beach, started taking Paxlovid after she tested positive for COVID in July. Determining her status after she came down with a dry cough and nausea upon returning from a cruise was not easy, she said.

She tested negative on at-home kits she got free from the government but did not trust the results because the kits had expired. She could no longer get free tests from Walgreens through her Medicare plan. Although she works remotely, she drove 45 minutes to the medical school where she is employed for a free test - and found out she was infected.

The experience left her frustrated and worried about the months ahead.

“All of those people who are walking around with COVID are not testing. They are giving it to other people. Nobody is really paying attention,” Grammerstorf said. “It’s important to offer them free so people do the responsible thing.”

Medicare and the five largest private insurers - United Healthcare, Aetna, Cigna, Anthem and Humana - no longer reimburse over-the-counter coronavirus tests for all beneficiaries, according to their websites, though some individual plans may differ. Medicaid continues to pay for no-cost tests through September 2024, after which coverage will vary by state. A program that allowed Medicaid programs to provide free testing to uninsured people ended with the public health emergency.

Free over-the-counter testing marked a major shift in the country’s pandemic response, giving Americans a low-hassle way to gather safely and break chains of transmission early. The free test-by-mail program - which sent more than 750 million tests to Americans - improved racial disparities in the pandemic with Black and White people taking advantage of it at similar rates, according to a CDC analysis, and African Americans far more likely to use those tests than ones purchased at stores.

“By removing that financial barrier, it made COVID testing a lot more accessible for those groups, which in turn improved the ability to identify illness and reduce spread,” said Latoya Hill, a senior policy analyst with KFF’s racial equity and health policy program.

With gaps in testing coverage and inconsistent access, health equity experts worry that coronavirus will spread more easily in low-income or predominantly Black and Latino communities where people are more likely to have underlying conditions and face greater complications from coronavirus.

“We are going to see a pattern we saw earlier in the pandemic of people who are from socially marginalized groups and communities having higher rates of infection,” said Lisa Cooper, director of the Johns Hopkins Center for Health Equity.

Libby Young, a 33-year-old nonprofit manager in New York, said she tests less frequently than she used to because she has to pay out-of-pocket. Money is tight because of medical expenses to treat long COVID symptoms that leave her fatigued after exertion. When she and her partner fell sick in July, they rationed tests they bought on Amazon. Her Google searches free testing in her Hudson Valley community produced nothing.

“Having any additional health expenses, plus medication I take, it’s a huge burden,” Young said. “It’s cost prohibitive and you often don’t test positive until day 3, 4 or 5.”

With a new school year looming or already underway, regular coronavirus testing is becoming untenable for parents who are used to children often having runny noses and coughs with a host of viruses circulating.

Kristin Riddick, a mom of three young children in Richmond, canceled a vacation in June after she and a son tested positive before their trip. The family decided not to test even when others became sick because of the costs and challenges of swabbing young children, but waited more than 10 days to return to work and day care.

“We have to be a little bit choosier about when we decide to test,” said Riddick, 32. “It’s just so hard to know when to pull them out and when not to, but we also don’t want to traumatize our kids by sticking things up their nose whenever.”

Sharon Nachman, chief of the division of pediatric infectious diseases at Stony Brook Children’s Hospital, said she’s hearing similar sentiments from the parents of her patients.

“They were like, ‘No, we don’t have any kits at home, and we are not spending money to buy those kits,’” Nachman said. “The consequences of not testing mean you don’t know. And if you don’t know, that means you can’t tell someone else.”