Progressively Widening Healthcare Costs in Long COVID Over Five Years

Background Long COVID affects millions worldwide, yet the long-term trajectory of healthcare costs remains poorly characterized. Prior studies with limited follow-up have documented elevated but stable excess costs, leaving uncertainty about whether the economic burden attenuates or persists over time. Methods We conducted a retrospective cohort study using electronic health record data from 12 hospitals and 20 community health centers (January 2018 through December 2024). Adults with documented SARS-CoV-2 infection were classified as having Long COVID using a validated precision phenotyping algorithm or as controls without Long COVID. We used two-part generalized estimating equation models to estimate adjusted quarterly healthcare costs over 20 quarters, decomposed costs into visit frequency and cost-per-visit components, and conducted subgroup and sensitivity analyses accounting for differential mortality. Results Among 143,544 adults (27,986 with Long COVID; 115,558 controls), the adjusted excess quarterly cost for Long COVID widened progressively rather than attenuating, increasing from $79 (95% CI, $48-$118) at baseline to $236 (95% CI, $176-$287) at quarter 19, a threefold increase in the cost differential. Long COVID was associated with 20% higher odds of any healthcare utilization (OR, 1.20; 95% CI, 1.18-1.23) and 30% higher costs when care was accessed (cost ratio, 1.30; 95% CI, 1.25-1.35). Visit frequency diverged over time, reaching 44% higher utilization by quarter 19, while cost-per-visit premiums remained stable. Excess costs concentrated in the upper distribution tail (99th percentile difference: $8,482). The widening trajectory was consistent across subgroups defined by hospitalization status, sex, and comorbidity burden. Cumulative 5-year excess costs were $7,124 per Long COVID patient after mortality adjustment. Conclusions Contrary to assumptions of post-acute recovery, Long COVID is associated with progressively widening healthcare costs over five years, driven primarily by increasing utilization rather than care intensity, suggesting an evolving chronic disease burden with substantial and growing economic implications.