The spread of the new Coronavirus has continued, with a number of cases showing up in countries like Iran, Italy, and South Korea. Coronavirus information is changing by the minute, so we’re back with another update.
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US Supreme Court Agrees to Review Affordable Care Act — for the Third Time
US Supreme Court Agrees to Review Affordable Care Act — for the Third Time
The fate of the Affordable Care Act (ACA) is once again in the hands of the US Supreme Court. On March 2, the court announced that it would hear a case challenging the health law, a wide-ranging measure that “touches the lives of most Americans, from nursing mothers to people eating at chain restaurants,” wrote Reed Abelson, Abby Goodnough, and Robert Pear in the New York Times. This will be the third time the court will rule on the ACA since President Barack Obama signed it on March 23, 2010.
“The justices will review a federal appeals court decision that found part of the law . . . unconstitutional and raised questions about whether the law in its entirety must fall,” reported Robert Barnes in the Washington Post. He noted that it is one of the first cases accepted for the Supreme Court term beginning October 5, which means a decision is not likely until spring or summer of 2021.
Should the court overturn the ACA, many Americans would lose the benefits afforded under the law. As Dylan Scott wrote in Vox, “everything would go: protections for preexisting conditions, subsidies that help people purchase insurance, the Medicaid expansion.”
Let’s break down each of those categories.
Protections for Preexisting Conditions
Before the ACA, people with preexisting conditions, which included common medical conditions like asthma, diabetes, and cancer, were denied health insurance or charged higher insurance premiums. Important benefits like maternity care and mental health services frequently were carved out of the benefit packages in health plans sold in the individual market — that is, outside of employer-sponsored coverage. An issue brief (PDF) by the Department of Health and Human Services estimated that up to 133 million nonelderly Americans have a preexisting condition.
As Andy Slavitt, the former administrator of the Centers for Medicare & Medicaid Services under President Obama, wrote on Twitter, examples of being charged more included “$4,270 more for asthma, $17,060 for pregnancy, and $160,510 for metastatic cancer.”
Under the ACA, insurers are no longer allowed to deny coverage or charge higher prices to people with preexisting conditions. But if the Supreme Court rules against the ACA, these protections would vanish.
Medicaid Expansion
A key provision of the ACA is expanded eligibility for enrollment in Medicaid, a federally funded state option adopted so far by 36 states and the District of Columbia. More than 12 million adults with low incomes have gained Medicaid coverage through this provision, and research comparing expansion and nonexpansion states has linked expanded Medicaid access to better health outcomes.
According to the Urban Institute, if the ACA is repealed, “the uninsurance rate across all expansion states would increase from 9% of the nonelderly under current law to 17% under repeal. In nonexpansion states, the uninsurance rate would increase from 15% of the nonelderly to 21%.” Many of the newly uninsured would be the result of losing the Medicaid coverage the ACA provided.
“The uninsured rate for Black Americans would increase from 11% to 20% without Obamacare,” Scott reported. “There would also be a dramatic spike in uninsurance among Hispanics.”
Subsidies to Help People Purchase Insurance
To expand access to affordable health insurance for those who can’t get it through their jobs, the ACA offers federal subsidies to people with low and moderate incomes who buy insurance through the ACA insurance exchanges. The subsidies take the form of premium tax credits and cost-sharing subsidies.
Approximately 9.2 million Americans receive federal subsidies, reported Abelson, Goodnough, and Pear. “On average, the subsidies covered $525 of a $612 monthly premium for customers in the 39 states that use the federal marketplace,” they wrote.
If the ACA is overturned and the subsidies are eliminated, the cost of health insurance would become unaffordable for many of those 9.2 million people, and the uninsured population would soar.
Polls Show Public Support for the ACA
According to the February 2020 KFF Health Tracking Poll, 55% of Americans say they now favor the ACA, a new high compared to approval ratings below 40% as recently as 2016. Today 85% of Democrats express favorable views of the law, compared to 53% of independents and 18% of Republicans.
Though overall support for the health law remains partisan, many of its provisions have broad bipartisan support, KFF staff wrote in Health Affairs. For instance, large majorities of Democrats (94%), independents (88%), and Republicans (77%) have a favorable view of the ACA’s health insurance exchanges, and most Democrats (80%), independents (71%), and Republicans (54%) view the Medicaid expansion favorably.
Rising Health Costs Worsen California’s Coronavirus Threat
The global spread of the novel coronavirus disease known as COVID-19 puts threats to the ACA into perspective. Despite the coverage gains made under the ACA, nearly 28 million Americans remain uninsured, and that number would rise if the law were overturned. As Chris Sloan, associate principal at the consulting firm Avalere Health, told Caitlin Owens in Axios, we “could see uninsured or underinsured patients . . . skipping necessary treatment because they believe they can’t afford it.”
“Some lawmakers are concerned that the tens of millions who are underinsured — Americans with high deductibles or limited insurance — may also be at risk of unexpected expenses as more and more people are exposed to the virus,” Reed Abelson and Sarah Kliff reported in the New York Times.
Kristof Stremikis, director of CHCF’s market analysis and insight team, wrote in a recent blog post, “In an era when the average deductible facing a working family in California now exceeds $2,700, it’s not hard to imagine how many people missed detection and treatment opportunities because they could not afford to pay for them.”
To address some of these concerns, the California Department of Insurance (PDF) and the Department of Managed Health Care (PDF) directed all commercial health plans and Medi-Cal plans to “immediately reduce cost-sharing (including, but not limited to, co-pays, deductibles, or co-insurance) to zero for all medically necessary screening and testing for COVID-19, including hospital, emergency department, urgent care, and provider office visits where the purpose of the visit is to be screened and/or tested for COVID-19.”
Similar policies have been announced by state regulators in Washington and New York, the San Francisco Chronicle reported.
Cartoon – The Executive Steering Committee
Cartoon – Lie by Omission?
Cartoon – Speaking Truth to Power
Cartoon – Progress Reporting
Cartoon – Leadership Listening
Anxiety over coronavirus grows on Capitol Hill
Pressure is mounting on congressional leaders to cancel votes and restrict activity in the Capitol to avert a coronavirus outbreak.
Several lawmakers appearing at the recent American Israel Public Affairs Committee (AIPAC) and Conservative Political Action Conference (CPAC) gatherings in the Washington, D.C., area interacted with individuals who have since tested positive for the highly contagious virus.
Both Sen. Ted Cruz (R-Texas) and Rep. Paul Gosar (R-Ariz.) said over the weekend they would self-quarantine after coming into contact with a person at CPAC who had tested positive.
Cruz, who had a brief interaction and shook hands with the individual, said he is not showing any symptoms of coronavirus, but would remain in Texas “out of an abundance of caution.”
Gosar, a dentist, said both he and his staff came in contact with the individual. The congressman said he would shut down his Washington office this week and follow Congress’s “tele-commute plan.”
Over the weekend, Congress’s medical office sent lawmakers an update on the CPAC encounters that supported the self-quarantines and suggested the chances of transmission were low.
“The public health authorities assessed each person’s contact with the ill individual,” reads the notice, which was obtained by The Hill. “The overall findings are considered to be a “low risk” to acquire SARS-Cov-2 (coronavirus) infection and they were advised on courses of action specific to their unique level of exposure.”
Others are taking self-imposed precautions, as well.
Rep. Liz Cheney (R-Wyo.), the third-ranking House Republican, opted to skip a leadership retreat on the Eastern Shore of Maryland over the weekend, with a spokesperson citing a need to protect “people in our families who are particularly vulnerable,” Politico reported.
As of Monday morning, more than 500 patients in the United States had been diagnosed with the virus across 34 states, according to a tally being kept by The New York Times.
Senate and House lawmakers were expected to travel back to Washington, with votes still scheduled for Monday afternoon and evening. And lawmakers across the country were boarding planes Monday morning to return to the nation’s capital, including those from coronavirus hot-spots like Seattle.
But a sense of anxiety permeated Capitol Hill, where many lawmakers — including the top three Democratic leaders — are in their 70s and 80s, travel constantly around the country for district visits and campaign events, and meet regularly with constituents and other interest groups.
“I don’t see how you keep asking a large group of elderly folks to fly on planes back and forth over the next few weeks,” said one House aide who’s been monitoring the situation on Capitol Hill.
Added a GOP lawmaker: “The most vulnerable population are people over 70 … which is all of the Democrat leadership and most chairman, and a third of the U.S. Senate.”
Still, many leaders and rank-and-file lawmakers believe closing the Capitol at this moment could send the wrong message to an already jittery public, setting off a wave of panic. On Monday, the Dow Jones industrial average tumbled more than 1,600 points on falling oil prices related to the coronavirus outbreak.
“Business should carry on,” the GOP lawmaker said.
A second staffer said that while leaders have given no signal of shuttering the Capitol, individual lawmakers are making their own contingency plans.
“Many offices including ours are preparing for some kind of total office building shutdown, shifting to telework, etc.,” the aide said.
Last week, the top congressional leaders received a partially classified briefing on the threat to the Capitol complex.
Afterward, Speaker Nancy Pelosi (D-Calif.) said the Capitol Police assured the lawmakers that the Capitol is well-secure, while the message from the Capitol physician’s office largely related to simple precautions related to personal hygiene, like washing hands and sneezing into tissues. Around the Capitol, illustrated signs have popped up in the bathrooms instructing visitors on proper hand-washing procedures.
“It’s not about testing everybody who comes into the building. That’s not realistic,” Pelosi said last Thursday. “But it is also, hopefully, that the message that goes out more globally is that people will be more responsible about their own preventative measures.”
She added: “Some of that sounds very basic and mundane, but it does prevent the spread.”
House Democratic leaders are expected to huddle Monday afternoon, ahead of the evening’s votes, where the coronavirus issue will almost certainly be front and center. Meanwhile, leadership offices are reaching out to members to encourage preparations in the event the Capitol is closed down.
“Offices are putting together emergency telework plans … and assessing IT needs, and encouraging off site meetings or phone calls,” said a third staffer.
Coronavirus and Healthcare Reform
At this writing, the number of COVID-19 cases worldwide has reached 100,000 with 3,500 deaths. These numbers will be higher by tomorrow.
What does this have to do with U.S. healthcare reform? A lot.
Two current background articles drive home the point that a well-functioning public health system is critical for responding to a pandemic like 2019 coronavirus disease (COVID-19), especially in its early phases. And it means that the healthcare system – including a robust public health infrastructure — should be about health, not just about profit and greed.
Let’s Put This in Context: Is COVID-19 “Just Another Flu”?
WHO reports that annual cases of influenza A and B worldwide range from 3 to 5 million, causing 290,000 to 650,000 respiratory deaths. That’s a lot more than COVID-19, at least so far. So what’s the big deal?
The big deal is that, This Is Not a Competition, not an either-or between influenza virus and coronavirus. Otherwise this would be like asking, Would you rather be killed by an airplane crash, by tobacco-related cancer, or by pollution-related pneumonia? The answer is, of course, none of the above.
What these types of deaths and illness have in common is being in part preventable by known public health measures, with different interventions needed for each one. Likewise, influenza A and B deaths are in part preventable. Prevention relies on the elaborate and sophisticated worldwide influenza vaccine program. It includes monitoring influenza strains alternating between Northern and Southern hemispheres, annual adjustment of vaccine components, production, distribution, and public messaging.
But unlike influenza, currently COVID-19 is not preventable, since vaccine development and testing will take a year or more. And WHO is modeling that COVID-19 is at best only partially containable by general non-pharmaceutical measures. For example, one worst-case model of the pandemic estimates that two-thirds of the world’s population could be infected, once it runs its course. This has epidemiologists scrambling to calculate the actual transmissibility and actual mortality rates so as to refine predictions more accurately and to help plans for mitigating its spread.
So, no, COVID-19 is not “just another flu,” as the President implied in a March 4 off-the-cuff interview. COVID-19 is to be sure, a “flu-like illness,” but it has unique (as yet not fully characterized) epidemiologic characteristics, and it requires a completely different public health strategy, at least in the short- and medium-term. The President is reckless to minimize either disease – both diseases are widespread and lethal — especially since proper public messaging is a key to rallying a coherent response by individuals, communities, and nations.
How Bad Could It Be? Comparison to 1918 Spanish Flu
Could the COVID-19 pandemic wreak the same devastation as the 1918 Spanish flu? Spanish flu eventually infected 500 million people worldwide, effectively 25 percent of the total global population. And it killed up to 100 million of them. “It left its mark on world history,” according to University of Melbourne professor James McCaw, a disease expert who mathematically modelled the biology and transmission of the disease, and who was quoted today by the Australian Broadcasting Company (ABC).
What SARS-CoV2 (severe acute respiratory syndrome-corona virus strain 2), the agent that causes COVID-19 disease, has in common with the H1N1/Spain agent is novelty, transmissibility, and lethality. Novelty means that it is antigenically new, so that no one in the world is already immune or even partially cross-immune. Transmissibility means it’s easily spread by aerosol (coughing) or surface contact (hand to nose). Lethality means its significant death rate.
On the one hand, Dr. McCaw hopes that public health measures against COVID-19 will be more effective than in 1918. For one, experts and the general public now know about viruses. In 1918, virology was in its infancy.
“We’re not going to see that sort of level of mortality, that mortality was driven by the social context of the outbreak,” predicts Dr. Kirsty Short, a University of Queensland virologist, also quoted by the ABC. “We had a viral outbreak, at the same time as the end of a world war.”
In addition, modern medicine means much better care is available now than it was then. “We’ve already got a lot of scientists working on novel therapies and novel vaccines to try to protect the general population,” Dr Short says.
Professor McCaw points to an apparent initial success in Wuhan Province. “What’s happened in China gives very clear evidence that we can get what’s called the ‘reproduction number’ under one. So at the moment in China, on average, each person infected with coronavirus is passing that infection on to fewer than one other person. If people hadn’t changed their behaviour, we would have expected somewhere around the millions of cases in China by now instead of the comparatively small number of around 100,000.” So, he says, it looks like the transmissibility of coronavirus can be significantly modified through social distancing and good hygiene.
On the other hand, best-case calculations from these Australian epidemiologists appear to discount other factors that could actually worsen the pandemic in 2020 compared with 1918 – rapid international travel and higher concentration of people in urban centers.
Both Dr. Short and Professor McCaw admit that in the early days of a pandemic accurate predictions remain difficult to make.
Nevertheless, they both make clear that in battling the coronavirus, the national and international public health systems – and the public’s trust in them – will be key.
Public Health Approach Is the Key
The importance of public health actions is underscored by a second report today by two experts from the Center for Strategic and International Studies, a Washington think tank.
Samuel Brannen and Kathleen Hicks write in Politico.com,
Last October, we convened a group of experts to work through what would happen if a global pandemic suddenly hit the world’s population. The disease at the heart of our scenario was a novel and highly transmissible coronavirus. For our fictional pandemic, we assembled about 20 experts in global health, the biosciences, national security, emergency response and economics at our Washington, D.C., headquarters. The session was designed to stress-test U.S. approaches to global health challenges that could affect national security. As specialists in national security strategic planning, we’ve advised U.S. Cabinet officials, members of Congress, CEOs and other leaders on how to plan for crises before they strike, using realistic but fictional scenarios like this one.
Here are their conclusions:
- Early and preventative actions are critical. They praise bipartisan Congressional support, including $50 million allocated to the CDC Infectious Diseases Rapid Response Reserve Fund, the passage of the 2019 Pandemic and All-Hazards Preparedness and Advancing Innovation Act, and the continuation of the Global Health Security Agenda.
- Communication is vital—but a decline in trust makes it harder. A critical ingredient for addressing pandemics is public order and obedience to protocols, rationing, and other measures that might be needed. Today, public trust in institutions and leaders is fragile, with routine evidence of intentional disinformation by foreign actors and elected officials alike. Misstatements about science are particularly damaging to the credibility of scientists and health officials seeking to guide response to the pandemic. Amid the hyperpartisanship of the current U.S. political environment in a presidential election year, politicization of the coronavirus outbreak could undermine public health efforts.
- International cooperation is also key. A virus knows no borders, as we have already seen with the real-world outbreak, and here a concerning change is heightened mistrust among countries. In the midst of trade tensions, fraying of international relationships, increased meddling by one country in the internal politics of another, and growing military tensions in hot spots around the globe, organizations such as the World Health Organization are increasingly caught in the middle, unable to play their intended neutral function.
- The private sector will be vital to managing the outbreak. There’s a good reason the President gathered pharmaceutical executives on Monday, March 2. The U.S. federal government is rightly at the center of the response to this likely pandemic, but it is the private sector that holds the bulk of the technological innovation to producing treatments and cures. One bit of good news on this front: There is already in place a highly effective public-private partnership structure in the Coalition for Epidemic Preparedness Innovations, which is making important contributions in the current race for a vaccine.
- The principal conclusion of our scenario was that leaders simply don’t take health seriously enough as a U.S. national security issue. Congress holds few hearings on the topic, especially in the defense committees, and the White House last year eliminated a top National Security Council position focused on the issue.
Healthcare Reform: We’re All in This Together
The impending epidemic of coronavirus in the U.S. also brings up important practical questions in the whole healthcare system, as reported in, for example, the New York Times and Kaiser Family Foundation.
Who will have access to testing? Who will pay? Will copays designed to keep patients with trivial illnesses from overutilizing the health system now backfire by delaying their testing and care? These kinds of questions are not at issue in countries with universal access.
However, even those countries will struggle to cope with the pandemic. For example, the United Kingdom faces a shortage of intensive care unit beds after a decade of downsizing its bed capacity.
This drives home the point that public health infrastructure is necessary but not sufficient for managing a pandemic. Namely, the U.K.’s bed shortage shows that public health is but one component of the broader task of maintaining a nation’s strategic risk preparedness. Calculating the surge capacity of inpatient beds for an unexpected pandemic emergency should not be left just to hospital administrators. This is also why the President should restore both bio-preparedness positions dropped by him in 2018 from the National Security Council and the Homeland Security Department.
Conclusion: Right, Privilege or, Rather, Social Contract?
Is healthcare a right or a privilege? The coronavirus tells us, Neither. Instead, this virus reminds us that healthcare is better framed as part of the social contract, the fundamental duty of governments to their citizens to defend them from clear threats, both currently present and foreseeable, not only military, but also economic, cyber, and in this case biological. Can Americans and their leaders put aside petty polemical bickering over healthcare reform and recognize the healthcare system for what it is, part of the backbone of a healthy, resilient nation?
Caught in the crossfire of payer-provider strategies
https://mailchi.mp/9e118141a707/the-weekly-gist-march-6-2020?e=d1e747d2d8
The aggressive push among insurers to purchase physician practices—one that mirrors the vertical integration strategies pursued by hospital systems over the past few years—has some asking what the end game looks like for health plans.
A recent investigative piece from Kaiser Health News shows where this payer-physician integration might lead. Focused on the activities of UnitedHealth Group in the New Jersey Medicaid market, the article describes a move by the company’s insurance subsidiary, UnitedHealthcare, to shift the Medicaid beneficiaries it covers in its Medicaid managed care plan into physician practices owned by its sister subsidiary, Optum.
That effort is the target of a lawsuit brought by some physician practices in the state, who allege they are losing patients as a result of an attempt by UnitedHealthcare to “narrow” its physician networks by terminating their contracts. It’s an obvious, and clever, strategy on the part of the insurer, which likely hopes to capture savings and generate greater revenue by integrating insurance and provision of care.
But as the piece describes, it’s proving significantly disruptive to the care of many patients, who are losing access to physicians with whom they’ve built relationships with over time. Insurers have pursued these strategies less aggressively in their commercial and Medicare businesses, turning instead to referral management tactics like specialist steerage, mandatory pre-authorizations, and discounted rates instead of shifting primary care patients care.
But, as in many other aspects of care, it may be easier to implement such aggressive “management” techniques in the low-income population, because patients have so few alternatives to care. As vertical integration strategies play out on both the hospital and insurer sides of the industry, it’s worth paying attention to how “grand strategy” of the sort depicted in our map above plays out on the ground, in the lives of individual patients.
HENRY KOTULA 