The Affordable Care Act (ACA) made historic strides in expanding access to health insurance coverage by covering an additional 20 million Americans.President Joe Biden ran on a platform of building upon the ACA and filling in its gaps. With Democratic majority in the Senate, aspects of his health care plan could move from idea into reality.
The administration’s main focus is on uninsurance, which President Biden proposes to tackle in three main ways: providing an accessible and affordable public option, increasing tax credits to help lower monthly premiums, and indexing marketplace tax credits to gold rather than silver plans.
However, underinsurance remains a problem. Besides the nearly 29 million remaining uninsured Americans, over 40% of working age adults are underinsured, meaning their out-of-pocket cost-sharing, excluding premiums, are 5-10% of household income or more, depending on income level.
High cost-sharing obligations—especially high deductibles—means insurance might provide little financial protection against medical costs beneath the deductible. Bills for several thousand dollars could financially devastate a family, with the insurer owing nothing at all. Recent trends in health insurance enrollment suggest that uninsurance should not be the only issue to address.
A high demand for low premiums
Enrollment in high deductible health plans (HDHP) has been on a meteoric rise over the past 15 years, from approximately 4% of people with employer-sponsored insurance in 2006 to nearly 30% in 2019, leading to growing concern about underinsurance. “Qualified” HDHPs, which come with additional tax benefits, generally have lower monthly premiums, but high minimum deductibles. As of 2020, the Internal Revenue Service defines HDHPs as plans with minimum deductibles of at least $1,400 for an individual ($2,800 for families), although average annual deductibles are $2,583 for an individual ($5,335 for families).
A common prescription has been to expand access to Health Savings Accounts (HSAs), with employer and individual contributions offsetting higher upfront cost-sharing. Employers often contribute on behalf of their employees to HSAs, but for individuals in lower wage jobs without such benefits or without extra income to contribute themselves, the account itself may sit empty, rendering it useless.
A recent article in Health Affairs found that HDHP enrollment increased from 2007 to 2018 across all racial, ethnic, and income groups, but also revealed that low-income, Black, and Hispanic enrollees were significantly less likely to have an HSA, with disparities growing over time. For instance, by 2018, they found that among HDHP enrollees under 200% of the federal poverty level (FPL), only 21% had an HSA, while 52% of those over 400% FPL had an HSA. In short, the people who could most likely benefit from an HSA were also least likely to have one.
If trends in HDHP enrollment and HSA access continue, it could result in even more Americans who are covered on paper, yet potentially unable to afford care.
Addressing uninsurance could also begin to address underinsurance
President Biden’s health care proposal primarily addresses uninsurance by making it more affordable and accessible. This can also tangentially tackle underinsurance.
To make individual market insurance more affordable, Biden proposes expanding the tax credits established under the ACA. His plan calls for removing the 400% FPL cap on financial assistance in the marketplaces and lowering the limit on health insurance premiums to 8.5% of income. Americans would now be able to opt out of their employer plan if there is a better deal on HealthCare.gov or their state Marketplace. Previously, most individuals who had an offer of employer coverage were ineligible for premium subsidies—important for individuals whose only option might have been an employer-sponsored HDHP.
Biden also proposes to index the tax credits that subsidize premiums to gold plans, rather than silver plans as currently done.This would increase the size of these tax credits, making it easier for Americans to afford more generous plans with lower deductibles and out-of-pocket costs, substantially reducing underinsurance.
The most ambitious of Biden’s proposed health policies is a public option, which would create a Medicare-esque offering on marketplaces, available to anyone. As conceived in Biden’s proposal, such a plan would eliminate premiums and having minimal-to-no cost-sharing for low-income enrollees; especially meaningful for under- and uninsured people in states yet to expand Medicaid.
Moving forward: A need to directly address underinsurance
More extensive efforts are necessary to meaningfully address underinsurance and related inequities. For instance, the majority of persons with HDHPs receive coverage through an employer, where the employer shares in paying premiums, yet cost-sharing does not adjust with income as it can in the marketplace. Possible solutions range from employer incentives to expanding the scope of deductible-exempt services, which could also address some of the underlying disparities that affect access to and use of health care.
The burden of high cost-sharing often falls on those who cannot afford it, while benefiting employers, healthy employees, or those who can afford large deductibles. Instead of encouraging HSAs, offering greater pre-tax incentives that encourage employers to reabsorb some of the costs that they have shifted on their lower-income employees could prevent the income inequity gap from widening further.
Under the ACA, most health insurance plans are required to cover certain preventative services without patient cost-sharing. Many health plans also exempt other types of services from the deductible – from generic drugs to certain types of specialist visits – although these exemptions vary widely across plans. Expanding deductible-exempt services to include follow-up care or other high-value services could improve access to important services or even medication adherence without high patient cost burden. Better educating employees about what services are exempt would make sure that patients aren’t forgoing care that should be fully covered.
Health insurance is complicated. Choosing a plan is only the start. More affordable choices are helpful only if these choices are fully understood, e.g., the tradeoff between an HDHP’s lower monthly premium and the large upfront out-of-pocket cost when using care. Investing in well-trained, diverse navigators to help people understand how their options work with their budget and health care needs can make a big difference, given that low health insurance literacy is related to higher avoidance of care.
The ACA helped expand coverage, but now it’s time to make sure the coverage provided is more than an unused insurance card. The Biden administration has the opportunity and responsibility to make progress not only on reducing the uninsured rate, but also in reducing disparities in access and patient affordability.
Ahead of a Supreme Court hearing in March to consider the legality of imposing work requirements as a condition of gaining Medicaid coverage, the Centers for Medicare and Medicaid Services (CMS) were expected to inform states on Friday of plans to rescind the controversial Trump administration policy.
Under the previous administration, ten states had applied for and were approved to use waiver authority to impose work requirements on Medicaid enrollees, and several other states were in the process of submitting applications. Critics (including us) have long held that such requirements, while nominally intended to introduce an element of “personal responsibility” to the safety-net coverage program for low-income Americans, actually serve to hinder access to care, and jeopardize the health status of already vulnerable populations; in addition, the added expense of program infrastructure often exceeds anticipated cost savings.
The policy was a favored project of former CMS administrator Seema Verma, who helped craft a similar program for the state of Indiana before joining the Trump administration. Among states granted waiver authority to impose work requirements, only Arkansas ever fully implemented the policy, before the legality of the waivers was challenged successfully in lower courts.
The Biden administration’s recision of work requirements is part of a broader reversal of Trump-era healthcare policies. This week the Justice Department notified the Supreme Court that it was switching sides in the closely watched case questioning the constitutionality of the Affordable Care Act (ACA), although the court has already heard the case and is expected to rule this spring. Starting Monday, the Biden team will also reopen the federal insurance marketplace for a special enrollment period, bolstering funding for outreach to ensure those eligible are aware of coverage options. And as part of its proposed COVID relief legislation, the administration plans toincrease subsidies to help individuals buy coverage on the exchanges, and to increase funding to support state Medicaid programs—policies that got a boost this week from a broad coalition of healthcare industry groups, including health plans, doctors, and hospitals.
As the administration rounds out its health policy team, we’d expect a continuedfocus on strengthening the core pillars of the ACA, along with a greater focus on ensuring health equity and addressing disparities. Meanwhile, two key positions remain unfilled: CMS administrator and commissioner of the Food and Drug Administration (FDA). These slots will likely remain open until the looming confirmation battle over Biden’s nominee for Secretary of Health and Human Services (HHS), California Attorney General Xavier Becerra, has been settled.
Early data on vaccine distribution by race and ethnicity show a mismatch between those population groups receiving the vaccine, and those that have been hardest hit by the pandemic. As the graphic above shows, Black and Hispanic Americans have thus far been vaccinated at considerably lower rates in many states compared to their share of population as a whole—and these disparities are likely to worsen as states shift focus to senior populations for priority access, moving away from prioritizing essential workers, who tend to be more racially diverse.
The White population skews older, which stands to widen disparities in the near-term. Another compounding issue: vaccine hesitancy.
A recent Morning Consult poll found that, despite an overall increase in overall vaccine willingness, Black Americans remain the most hesitant, with only 48 percent willing to get the vaccine.
Meanwhile, Black and Hispanic Americans continue to be disproportionately impacted by COVID, with hospitalization and death rates nearly three to four times greater than those of White Americans.
Hesitancy will become an increasingly urgent problem as larger swathes of the population become eligible for vaccination, especially given that communities of color tend to be younger, as shown above.
As a warehouse manager at a Food 4 Less in Los Angeles, Norma Leiva greets delivery drivers hauling in soda and chips and oversees staff stocking shelves and helping customers. At night, she returns to the home she shares with her elderly mother-in-law, praying the coronavirus isn’t traveling inside her.
A medical miracle at the end of last year seemed to answer her prayers: Leiva, 51, thought she was near the front of the line to receive a vaccine, right after medical workers and people in nursing homes. Now that California has expanded eligibility to millions of older residents — in a bid to accelerate the administration of the vaccines — she is mystified about when it will be her turn.
“The latest I’ve heard is that we’ve been pushed back. One day I hear June, another mid-February,” said Leiva, whose sister, also in the grocery business, was sickened last year with the virus, which has pummeled Los Angeles County — the first U.S. county to record 1 million cases. “I want the elderly to get it because I know they’re in need of it, but we also need to get it, because we’re out there serving them. If we’re not healthy, our community’s not healthy.”
Delaying vaccinations for front-line workers, especially food and grocery workers, has stark consequences for communities of color disproportionately affected by the pandemic. “In the job we do,” Leiva said, “we are mostly Blacks and Hispanics.”
Many states are trying to speed up a delayed and often chaotic rollout of coronavirus vaccines by adding people 65 and older to near the front of the line. But that approach is pushing others back in the queue, especially because retired residents are more likely to have the time and resources to pursue hard-to-get appointments. As a result, workers who often face the highest risk of exposure to the virus will be waiting longer to get protected, according to experts, union officials and workers.
The shifting priorities illuminate political and moral dilemmas fundamental to the mass vaccination campaign: whether inoculations should be aimed at rectifying racial disparities, whether the federal government can apply uniform standards and whether local decision-making will emphasize more than ease of administration.
Speed has become all the more critical with the emergence of highly transmissible variants of the virus. Only by performing 3 million vaccinations a day — more than double the current rate — can the country stay ahead of the rapid spread of new variants, according to modeling conducted by Paul Romer, a Nobel Prize-winning economist.
But low-wage workers without access to sick leave are among those most likely to catch and transmit new variants, said Richard Besser, president of the Robert Wood Johnson Foundation and former acting director of the Centers for Disease Control and Prevention. Because there are not enough doses of the vaccines to immunize front-line workers and everyone over 65, he said, officials should carefully weigh combating the pernicious effects of the virus on communities of color against the desire to expedite the rate of inoculation.
“If the obsession is over the number of people vaccinated,” Besser said, “we could end up vaccinating more people, while leaving those people at greatest risk exposed to ongoing rates of infection.”
The move to broaden vaccine availability to a wider swath of the elderly population — backed by Trump administration officials in their final days in office and members of President Biden’s health team — marks a departure from expert guidance set forth in December, as the vaccine rollout was getting underway.
A panel of experts advising the CDC recommended that the second priority group include front-line essential workers, along with adults 75 and older. The guidance represented a compromise between the desire to shield people most likely to catch and transmit the virus — because they cannot socially distance or work from home — and the effort to protect people most prone to serious complications and death.
People of color and immigrants are overrepresented not just in grocery jobs but also in meatpacking, public transit and corrections facilities, where outbreaks have taken a heavy toll. Black and Latino Americans are three to four timesmore likely than White people to be hospitalized and almost three times more likely to die of covid-19, the illness caused by the coronavirus, according to the CDC.
The desire to make vaccine administration equitable was central to recommendations from the Advisory Committee on Immunization Practices.
“We cannot abandon equity because it’s hard to measure and it’s hard to do,” Grace Lee, a committee member and a pediatrics professor at Stanford University’s School of Medicine, said at the time.
On Wednesday at a committee meeting, Lee said officials need both efficiency and equity to “ensure that we are accountable for how we’re delivering vaccine.”
“Absolutely agree we do not want any doses in freezers or wasted in any way,” Lee said.
But efficiency has won out in most places.
Some state leaders, such as Florida Gov. Ron DeSantis (R) and Texas Gov. Greg Abbott (R), acted on their own, lowering the age threshold to 65 soon after distribution began last year. Others followed with the blessing of top federal officials.
Biden’s advisers have said equity will be central to their efforts, calling access in underserved communities a “moral imperative” and promising, in a national vaccination strategy document, “we remain focused on building programs to meet the needs of hard-to-reach and high-risk populations.” In the meantime, they have similarly encouraged states to broaden vaccine availability to a larger segment of their older populations without providing guidance about how to ensure front-line workers remain a priority.
Experts studying health disparities say prioritizing people over 65 disproportionately favors White people, because people of color, especially Black men, tend to die younger, owing to racism’s effect on physical health. Twenty percent of White people are 65 or over, while just 9 percent of people of color are in that age group, according to federal figures.
“People are thinking about risk at an individual level as opposed to at a structural level. People are not understanding that where you work and where you live can actually bring more risks than your age,” said Camara Phyllis Jones, a family physician, epidemiologist and past president of the American Public Health Association. “It’s worse than I thought.”
The constantly changing priorities have made the uneven rollout all the more difficult to navigate. There is confusion over when, where and how to get shots, with different jurisdictions taking different approaches in an illustration of the nation’s decentralized public health system.
While praising the effort to expand access and speed up the administration of shots, Marc Perrone, president of the United Food and Commercial Workers International Union, said increasing reliance on age-based eligibility “must not come at the expense of the essential workers helping families put food on the table during this crisis.
“Public health officials must work with governors in all 50 states to end the delays and act swiftly to distribute the vaccine to grocery and meatpacking workers on the front lines, before even more get sick and die,” he said.
Mary Kay Henry, president of the Service Employees International Union, said the only way to ensure front-line workers get the vaccines they need is to involve them and their union representatives in decisions about eligibility and access. Unions, she said, could also be tapped to conduct outreach in hard-to-reach communities, including those not conversant in English.
“Essential workers who’ve been on the front lines both in health care but also across the service and care sectors — child care, airline, janitorial, security — face extraordinary risk,” she said.
Leiva, a 33-year member of UFCW Local 770, said the celebration of essential workers should come with recognition of their sacrifice, which is unevenly felt across racial groups. When the virus tore through the grocery store, she said, “every single one of them in that cluster was Hispanic.”
But with hospitals dangerously full in recent weeks, and less than half of distributed vaccine doses administered, many states broadened their top priority groups to include older adults, hoping to lessen the burden on hospitals and expedite vaccine administration.
Protecting people 65 and older, officials say, saves the lives of those who face the gravest consequences and reduces the stress on intensive care units. Risk for severe covid-19 illness increases with age; 8 out of 10 deaths reported in the United States have been in people 65 and older.
Older people in the United States have also encountered enormous hurdles in gaining access to the vaccines. Faced with overloaded sign-up websites and jammed phone lines, they have sometimes spent nights waiting in line.
In more than half the states — at least 28, by one count — people 65 and older are in the top two priority groups, behind health-care workers and residents in long-term care facilities. As a result, front-line workers either fall behind the older group or are squeezed into the same pool, according to a Kaiser Family Foundation analysis.
“When you make that pool of eligible people much bigger, you’re creating much longer wait times for some of these groups,” said Jennifer Kates, a senior vice president at the foundation.
Front-line workers often labor in crowded conditions. Some live in multigenerational households. By contrast, many older adults are retired, have greater access to sign-up portals and have more time to wait in lines outside of clinics, health officials said.
“The 65-year-old person who is wealthier and can stay home and isn’t working and is retired and can ride it out for another two months … is less likely to get infected than the person who has to go outside every day for work,” said Roberto B. Vargas, assistant dean for health policy at Charles R. Drew University of Medicine and Science in Los Angeles.
In California, Gov. Gavin Newsom (D) announced Jan. 13 that the state was “significantly increasing our efforts to get these vaccines administered, get them out of freezers and get them into people’s arms” by increasing the number of people eligible to receive shots. “Everybody 65 and over — about 6.6 million Californians — we are now pulling into the tier to make available vaccines.”
On Jan. 25, Newsom said the state would move to an age-based eligibility system after vaccinating those now at the front of the line, including health-care workers, food and agriculture workers, teachers, emergency personnel and seniors 65 and older.
The abrupt changes confused local health officials.
Julie Vaishampayan, public health officer in San Joaquin Valley’s Stanislaus County, said the county had just finished vaccinating health-care workers and was getting ready to reach out to farm laborers at a tomato-packing company and food-processing workers. When the state added those 65 and older, the county had to pivot abruptly,as it faced a quintessential supply-and-demand dilemma.
“There isn’t enough vaccine to do it all, so how do we balance?” she said in an email. “This is really hard.”
In Tennessee, teachers were initially promised access but then were told to wait until people 70 and older got their shots. The state’s health commissioner, Lisa Piercey, said she was moving more gradually through the age gradations so as not to crowd out workers, treating the federal framework as guidance, which is often how officials have characterized it. “It’s not an either/or situation,” she said in an interview this month.
But with vaccine supply sharply limited, priorities had to be narrowed. By vaccinating older residents, she said, the state was also protecting its medical infrastructure by reducing the likelihood that older people, who are more likely to be hospitalized, would fall ill. Once there is more supply, she said, she would be able to amplify aspects of the state’s planning geared toward underserved and hard-to-reach populations. “I can’t wait to manifest that equity plan.”
In Nebraska, the health department in Douglas County, which includes Omaha, prioritized older residents over “critical industry workers who can’t work remotely” after the state expanded eligibility to residents 65 and older, according to a January news release. Meatpacking workers, grocery store employees, teachers and public transit workers were bumped lower in line.
Omaha’s teachers union had wanted its approximately 4,100 members to get shots before the district resumes full-time, in-person instruction for elementary and middle school students Tuesday. Now, they must wait until late spring, said Robert Miller, president of the Omaha Education Association.
“The fear, it goes hand in glove with going back to school five days a week,” he said, despite CDC reports that schools operating in person have seen scant transmission. “We’ve had some teachers who have multigenerational homes, who live in the basement, … and they can’t interact with their parents. We have some teachers who are staying at a different apartment away from their elder loved ones.”
Some state leaders sought to defend broadening eligibility to more of the elderly population, saying it was consistent with efforts to address racial disparities. Illinois had reduced the age requirement to 65, Gov. J.B. Pritzker (D) said recently, “in order to reduce covid-19 mortality and limit community spread in Black and Brown communities.” His office did not respond to a request for comment about how lowering the age threshold would have that effect.
In Massachusetts, state leaders announced Jan. 25 that people 65 and older and those with at least two high-risk medical conditions were next in line, ahead of educators and workers in transit, utility, food and agriculture, sanitation, and public works and public health.
That means Dorothy Williams, who runs a day-care center in a predominantly Black community where the infection rate is among the highest in Boston, has to wait. Her center stayed open throughout the pandemic, caring for children of essential workers, many of them in low-wage jobs in hospitals or nursing homes.
She recognizes the long hours and the exposure risks of those health-care aides. That means “we’re exposed,” she said, “each and every single day.” She has been able to keep the coronavirus at bay, but two weeks ago, she had a scare that forced her to close and get everyone tested after a child became ill. The tests came back negative, but the fear remains.
“And we believe that we’ll soon be able to confirm the purchase of an additional 100 million doses for each of the two FDA-authorized vaccines: Pfizer and Moderna,” Biden said. “That’s 100 million more doses of Pfizer and 100 million more doses of Moderna — 200 million more doses than the federal government had previously secured. Not in hand yet, but ordered. We expect these additional 200 million doses to be delivered this summer.”
After review of the current vaccine supply from manufacturing plants, the federal government believes it can increase overall weekly vaccination distribution to states, tribes, and territories from 8.6 million doses to a minimum of 10 million doses, starting next week.
But the pandemic is expected to get worse before it gets better, Biden said, with experts predicting the death toll as likely to top 500,000 by the end of February.
“But the brutal truth is: It’s going to take months before we can get the majority of Americans vaccinated. Months. In the next few months, masks — not vaccines — are the best defense against COVID-19,” he said.
WHY THIS MATTERS
The increases in the total vaccine order in the United States from 400 million ordered to 600 million doses will be enough vaccine to fully vaccinate 300 Americans by the end of the summer or the beginning of fall, Biden said.
“It’ll be enough to fully vaccinate 300 [million] Americans to beat this pandemic — 300 million Americans,” he said. “And this is an aggregate plan that doesn’t leave anything on the table or anything to chance, as we’ve seen happen in the past year.”
Biden’s team said they found the vaccine program to be in worse shape than they thought it would be and that they were starting from scratch.
“But it’s also no secret that we have recently discovered, in the final days of the transition — and it wasn’t until the final days we got the kind of cooperation we needed — that once we arrived, the vaccine program is in worse shape than we anticipated or expected,” Biden said.
Governors have been guessing at what they’ll receive for vaccine shipments, the president said.
The federal government is working with the private industry to ramp up production of vaccine and protective equipment such as syringes, needles, gloves, swabs and masks. The team has already identified suppliers and is working with them to move the plan forward.
Also, the Federal Emergency Management Agency is being directed to to stand up the first federally-supported community vaccination centers and to make vaccines available to thousands of local pharmacies beginning in early February.
THE LARGER TREND
Last week, Biden signed a declaration to begin reimbursing states 100% for the use of their National Guard to help the COVID-19 relief effort, both in getting sites set up and in using some of their personnel to administer the vaccines.
Biden has also said he wants to expand testing, which will help reopen schools and businesses.
He has formalized the Health Equity Task Force to ensure that the most vulnerable populations have access to vaccines.
He is also pushing for a $1.9 trillion relief package.
Hardly one month into 2021, the pressing priorities facing healthcare leaders are abundantly clear.
First, we will be living in a world preoccupied by COVID-19 and vaccination for many months to come. Remember: this is a marathon, not a sprint. And the stark reality is that the vaccination rollout will continue well into the summer, if not longer, while at the same time we continue to care for hundreds of thousands of Americans sickened by the virus. Despite the challenges we face now and in the coming months in treating the disease and vaccinating a U.S. population of 330 million, none of us should doubt that we will prevail. Despite the federal government’s missteps over the past year in managing and responding to this unprecedented public health crisis, historians will recognize the critical role of the nation’s healthcare community in enabling us to conquer this once-in-a-generation pandemic.
While there has been an overwhelming public demand for the vaccine during the past couple of weeks, there remains some skepticism within the communities we serve, including some of the most-vulnerable populations, so healthcare leaders will find themselves spending time and energy communicating the safety and efficacy of vaccines to those who may be hesitant. This is a good thing. It is our responsibility to share facts, further public education and influence public policy.COVID-19 has enhanced public trust in healthcare professionals, and we can maintain that trust if we keep our focus on the right things — namely, how we improve the health of our communities.
And as healthcare leaders diligently balance this work, we also have a great opportunity to reimagine what our hospitals and health systems can be as we emerge from the most trying year of our professional lifetimes. How do you want your hospital or system organized? What kind of structural changes are needed to achieve the desired results? What do you really want to focus on? Amid the pressing priorities and urgent decision-making needed to survive, it is easy to overlook the great reimagination period in front of us. The key is to forget what we were like before COVID-19 and reflect upon what we want to be after.
These changes won’t occur overnight. We’ll need patience, but here are my thoughts on five key questions we need to answer to get the right results.
1. How do you enhance productivity and become more efficient? Throughout 2021, most systems will be in recovery mode from COVID’s financial bruises. Hospitals saw double-digit declines in inpatient and outpatient volumes in 2020, and total losses for hospitals and health systems nationwide were estimated to total at least $323 billion. While federal relief offset some of our losses, most of us still took a major financial hit. As we move forward, we must reorganize to operate as efficiently as possible. Does reorganization sound daunting? If so, remember the amount of reorganization we mustered to work effectively in the early days of the pandemic. When faced with no alternative, healthcare moved heaven and earth to fulfill its mission. Crises bring with them great clarity. It’s up to leaders to keep that clarity as this tragic, exhausting and frustrating crisis gradually fades.
2. How do you accelerate digital care? COVID-19 changed our relationship with technology, personally and professionally. Look at what we accomplished and how connected we remain. We were reminded of how high-quality healthcare can go unhindered by distance, commutes and travel constraints with the right technology and telehealth programs in place. Health system leaders must decide how much of their business can be accommodated through virtual care so their organizations can best offer convenience while increasing access. Oftentimes, these conversations don’t get far before confronting doubts about reimbursement. Remember, policy change must happen before reimbursement catches up. If you wait for reimbursement before implementing progressive telehealth initiatives, you’ll fall behind.
3. How will your organization confront healthcare inequities? In 2020, I pledged that Northwell would redouble its efforts and remain a leader in diversity and inclusion. I am taking this commitment further this year and, with the strength of our diverse workforce, will address healthcare inequities in our surrounding communities head-on. This requires new partnerships, operational changes and renewed commitments from our workforce. We need to look upstream and strengthen our reach into communities that have disparate access to healthcare, education and resources. We must push harder to transcend language barriers, and we need our physicians and medical professionals of color reinforcing key healthcare messages to the diverse communities we serve. COVID-19’s devastating effect on communities of color laid bare long-standing healthcare inequalities. They are no longer an ugly backdrop of American healthcare, but the central plot point that we can change. If more equitable healthcare is not a top priority, you may want to reconsider your mission. We need leaders whose vision, commitment and courage match this moment and the unmistakable challenge in front of us.
4. How will you accommodate the growing portion of your workforce that will be remote?Ten to 15 percent of Northwell’s workforce will continue to work remotely this year. In the past, some managers may have correlated remote work and teams with a decline in productivity. The past year defied that assumption. Leaders now face decisions about what groups can function remotely, what groups must return on-site, and how those who continue to work from afar are overseen and managed. These decisions will affect your organizations’ culture, communications, real estate strategy and more.
5. How do you vigorously hold onto your cultural values amid all of this change? This will remain a test through 2021 and beyond. Culture is the personality of your organization. Like many health systems and hospitals, much of Northwell’s culture of connectedness, awareness, respect and empathy was built through face-to-face interaction and relationships where we continually reinforced the organization’s mission, vision and values. With so many employees now working remotely, how can we continue to bring out the best in all of our people? We will work to answer that question every day. The work you put in to restore, strengthen and revitalize your culture this year will go a long way toward cementing how your employees, patients and community come to see your organization for years to come. Don’t underestimate the power of these seemingly simple decisions.
While we’ve been through hell and back over the past year, I’m convinced that the healthcare community can continue to strengthen the public trust and admiration we’ve built during this pandemic. However, as we slowly round the corner on COVID-19, our future success will hinge on what we as healthcare organizations do now to confront the questions above and others head-on. It won’t be quick or easy and progress will be a jagged line. Let’s resist the temptation to return to what healthcare was and instead work toward building what healthcare can be. After the crisis of a lifetime, here’s our opportunity of a lifetime. We can all be part of it.
As vaccine eligibility guidelines have expanded to include adults over 65, we’ve heard from several friends and acquaintances looking for the inside scoop on getting a place in line. They’ve heard that their local health system is taking appointments, but only for established patients—do we know someone at the local system who could help them (or their mother, or their aunt with Stage IV cancer) get the shot?
One acquaintance was livid that his local hospital was prioritizing established patients:“They’re just rewarding people who have already paid them money. Is that fair?” It’s likely that system was making decisions based not on prior business relationships, but rather logistics. If patients are already “in the system”, they can be contacted and scheduled through the patient portal, fill out information online, and have their doses tracked in the EMR.
As health systems have been thrust into leading frontline vaccine distribution some have recognized an unprecedented opportunity to earn loyalty by connecting current and potential patients with the vaccine.
Outreach must provide clear information around vaccine access and how eligibility decisions are made(consider the difference in message between “we’re offering vaccines to current patients only”, and “because established patients can be quickly scheduled and monitored, we are beginning with this group, and plan to expand quickly”).
Systems’ ultimate goal should be getting vaccines to as many people as possible, as fast as possible, given supply and resource constraints.
Beyond the initiatives directly tied to COVID relief, President Biden’s healthcare agenda includes a broader bolstering of the protections and coverage mechanisms in the Affordable Care Act (ACA), as well as the rollback of several of the previous administration’s regulatory changes. We’ve outlined that agenda in the graphic below, as well as highlighting key members of the Biden healthcare team.
While much will depend on how the COVID pandemic continues to unfold, and how successful Biden is at striking bipartisan compromises with a closely divided Congress, we’re watching closely for the answers to several key questions:
(1) how aggressive can and will the new administration be in unwinding Trump-era reforms, particularly regarding Medicaid work requirements;
(2) what will be the thrust of Biden’s antitrust policyin the healthcare space;
(3) how hard will Biden be willing to push for expanded subsidies for individuals purchasing insurance on the ACA exchanges;
(4) how will the Biden team build on the transparency measures implemented by the Trump administration; and
(5) how will the new administration use payment reforms and other regulations to address racial and other disparities in healthcare?
All of that preceded by one burning question that has us holding our breath: who will Biden pick to run the all-important Centers for Medicare and Medicaid Services?
Neighborhoods in cities like Chicago are rapidly becoming places where people can’t fill medical prescriptions locally because their drugstores have shuttered or don’t accept Medicaid.
Why it matters:The pandemic has accelerated the growth of “pharmacy deserts” as unprofitable and less-profitable stores have closed. It’s a worrisome trend for the urban poor, who are less likely to try online pharmacies and more likely to let their drug regimens lapse when they can’t get medication locally.
Driving the news: Effective Dec. 1, Medicaid patients in Illinois — of which there are 400,000, per the Chicago Tribune — could no longer get their prescriptions filled at Walgreens, a prevalent chain headquartered in a Chicago suburb.
The change came because Aetna, which provides contracts with the state of Illinois to serve Medicaid recipients, dropped Walgreens as a provider. CVS — a top Walgreens rival — owns Aetna as well as the pharmacy benefits manager CVS Caremark.
CVS “has no pharmacies in five key West Side neighborhoods,” per the Tribune.
Illinois state Rep. La Shawn Ford called Aetna’s decision “pathetic” and told the Tribune, “It’s an attack not just on Black people, but on those that are struggling during the pandemic.”
The backstory:Researcher Dima Qato coined the term “pharmacy desert” in a 2014 article that found there were far fewer pharmacies in Chicago’s Black neighborhoods than in white and mixed neighborhoods.
Medicaid policies like the one in Illinois “are all over the country, where Medicaid dictates where and where you can go fill your medication,” Qato tells Axios. “And that leads to certain pharmacies having less patients in them, which leads to less profits, which leads to closures.”
Qato — who recently took a post as a professor at the University of Southern California, and is in the process of moving from Chicago — said that the new Medicaid policy in Illinois is generating “a lot of outrage in the community right now.”
Per Qato’s definition, people live in a “pharmacy desert” if they can’t fill a prescription within a half-a-mile of their homes (for low-income people without cars), and a mile for others.
“We’ve estimated it for Chicago at a third of the city’s population, with substantial difference by racial composition,” Qato says.
Between the lines:Because pharmacies get the lowest reimbursements for filling Medicaid prescriptions, they’re more likely to close stores in low-income neighborhoods and open them in wealthy ones, notes Antonio Ciaccia, chief strategy officer of 3 Axis Advisors, a consultancy focused on the drug supply chain.
“We’re seeing a general retreat from impoverished areas,” said Ciaccia, who serves as an adviser to the American Pharmacy Association.
Of note:Studies draw a direct line between pharmacy closures and people stopping their vital medications — with terrible health outcomes.
Adults over 50 were more likely to drop their cardiovascular pills after their local drug store closed, according to a study published in the Journal of the American Medical Association in 2019 (of which Qato is the lead author).
Benjy Renton, the Middlebury College senior who has been closely tracking the COVID-19 outbreak, noted on Twitter that pharmacy deserts could hold back the administration of vaccines.
What’s next:While “food deserts,” where inner-city residents lack access to fresh and healthy groceries, are a bigger problem in places like New York City, pharmacy access is a growing concern. The number of drugstores has declined 20% in NYC since 2016, according to Jonathan Bowles, executive director of the Center for an Urban Future.
“I for one will miss the 70 Duane Reades that closed this year,” was the headline of an an article that New York Magazine’s “Curbed” ran on Dec. 30. (Duane Reade is owned by Walgreens.)
The annual J.P. Morgan Healthcare Conference is one of the best ways to diagnose the financial condition of the healthcare industry. Every January, every key stakeholder — providers, payers, pharmaceutical companies, tech companies, medical device and supply companies as well as bankers, venture capital and private equity firms — comes together in one exam room, even when it is virtual, for their annual check-up. But as we all know, this January is unlike any other as this past year has been unlike any other year.
You would have to go back to the banking crisis of 2008 to find a similar moment from an economic perspective. At the time, we were asking, “Are banks too big to fail?” The concern behind the question was that if they did fail, the economic chaos that would follow would lead to a collapse with the consumer ultimately picking up the tab. The rest is history.
Healthcare is “Too Vital to Fail”
2020 was historic in too many ways to count. But in a year when healthcare providers faced the worst financial crisis in the history of healthcare, the headline is that they are still standing. And what they proved is that in contrast to banks in 2008 that were seen by many as “too big to fail,” healthcare providers in 2020 proved that they were “too vital to fail.”
One of the many unique things about the COVID-19 pandemic is we are simultaneously experiencing a health crisis, where healthcare providers are the front line in the battle, and an economic crisis, felt in a big way in healthcare given the unique role hospitals play as the largest employer in most communities. Hospitals and health systems have done the vast majority of testing, treating, monitoring, counseling, educating and vaccinating all while searching for PPE and ventilators, and conducting clinical trials. And that’s just the beginning of the list.
Stop and think about that for a minute. What would we have done without them? Thinking through that question will give you some appreciation for the critical, challenging and central role that healthcare providers have had to play over the past year.
Simply stated, healthcare providers are the heart of healthcare, both clinically (essentially 100 percent of the care) and financially (over 50 percent of the $4 trillion annual spend on U.S. healthcare). Over the last year they stepped up and they stepped in at the moment where we needed them the most. This was despite the fact that, like most businesses, they were experiencing calamitous losses with no assurances of any assistance.
Healthcare is “Pandemic-Proof”
This was absolutely the worst-case scenario and the biggest test possible for our nation’s healthcare delivery system. Patient volume and therefore revenue dropped by over 50 percent when the panic of the pandemic was at its peak, driving over $60 billion in losses per month across hospitals and healthcare providers. At the same time, they were dramatically increasing their expenses with PPE, ventilators and additional staff. This was not heading in a good direction. While failure may not have been seen as an option, it was clearly a possibility.
The CARES Act clearly provided a temporary lifeline, providing funding for our nation’s hospitals to weather the storm. While there are more challenging times ahead, it is now clear that most are going to make it to the other side. The system of care in our country is often criticized, but when faced with perhaps the most challenging moment in the history of healthcare, our nation’s hospitals and health systems stepped up heroically and performed miraculously. The work of our healthcare providers on the front line and those who supported them was and is one thing that we all should be exceptionally proud of and thankful for.In 2020, they proved that not only is our nation’s healthcare system too vital to fail, but also that it is “pandemic proof.”
Listening to Front Line at the 2021 J.P. Morgan Healthcare Conference
There has never been a more important year to listen to the lessons from healthcare providers. They are and were the front line of our fight against COVID-19. If there was a class given about how to deal with a pandemic at an institutional level, this conference is where those lessons were being taught.
This year at the J.P. Morgan Healthcare Conference, CEOs, and CFOs from many of the most prestigious and most well-respected health systems in the world presented including AdventHealth, Advocate Aurora Health, Ascension, Baylor Scott & White Health, CommonSpirit Health, Henry Ford Health System, Intermountain Healthcare, Jefferson Health, Mass General Brigham, Northwell Health, OhioHealth, Prisma Health, ProMedica Health System, Providence, Spectrum Health and SSM Health.
I’ve been in healthcare for 30 years and this is my fifth year of writing up the summary of the non-profit provider track of the conference for Becker’s Healthcare to help share the wisdom of the crowd of provider organizations that share their stories. Clearly, this year was different and not because the presentations were virtual, but because they were inspirational.
What did we learn? The good news is that they have made many changes that have the potential to move healthcare in a much better direction and to get to a better place much faster. So, this year instead of providing you a nugget from each presentation, I am going to take a shot at summarizing what they collectively have in motion to stay vital after COVID.
10 Moves Healthcare Providers are Making to Stay Vital After-COVID
As a leader in healthcare, you will never have a bigger opportunity to drive change than right now. Smart leaders are framing this as essentially “before-COVID (BC)” and “after-COVID (AC)” and using this moment as their burning platform to drive change. Credit to the team at Providence for the acronym, but every CEO talked about this concept. As the saying goes, “never let a good crisis go to waste.” Well, we’ve certainly had a crisis, so here is a list of what the top health systems are doing to ensure that they don’t waste it and that they stay vital after-COVID:
1. Take Care of Your Team and They’ll Take Care of You: In a crisis, you can either come together as a team or fall apart. Clearly there has been a significant and stunning amount of pressure on healthcare providers. Many are fearing that mental health might be our nation’s next pandemic in the near future because they are seeing it right now with their own team. Perhaps one of their biggest lessons from this crisis has been the need to address the mental, physical and spiritual health of both team members as well as providers. They have put programs in place to help and have also built a tremendous amount of trust with their team by, in many cases, not laying off and/or furloughing employees. While they have made cuts in other areas such as benefits, this collective approach proved incredibly beneficial. And the last point here that relates to thinking differently about their team is that similar to other businesses, many health systems are making remote arrangements permanent for certain administrative roles and moving to a flexible approach regarding their team and their space in the future.
2. Focus on Health Equity, Not Just Health Care: This was perhaps the most notable and encouraging change from presentations in past years at J.P. Morgan. I have been going to the conference for over a decade, and I’ve never heard someone mention this term or outline their efforts on “health equity” — this year, nearly everyone did. In the past, they have outlined many wonderful programs on “social determinants of health,” but this year they have seen the disproportionate impact of COVID on low-income communities bringing the ongoing issue of racial disparities in access to care and outcomes to light. As the bedrock of employment in their community, this provides an opportunity to not just provide health care, but also health equity, taking an active role to help make progress on issues like hunger, homelessness, and housing. Many are making significant investments in a number of these and other areas.
3. Take the Lead in Public Health — the Message is the Medicine:One of the greatest failings of COVID, perhaps the greatest lesson learned, is the need for clear and consistent messaging from a public health perspective. That is a role that healthcare providers can and should play. In the pandemic, it represented the greatest opportunity to save lives as the essence of public health is communication — the message is the medicine. A number of health systems stepped into this opportunity to build trust and to build their brand, which are essentially one in the same. Some organizations have created a new role — a Chief Community Health Officer — which is a good way to capture the work that is in motion relative to social determinants of health as well as health equity. Many understand the opportunity here and will take the lead relative to vaccine distribution as clear messaging to build confidence is clearly needed.
4. Make the Home and Everywhere a Venue of Care:A number of presenters stated that “COVID didn’t change our strategy, it accelerated it.” For the most part, they were referring to virtual visits, which increased dramatically now representing around 10 percent of their visits vs. 1 percent before-COVID. One presenter said, “Digital has been tested and perfected during COVID,” but that is only considering the role we see digital playing in this moment. It is clear some organizations have a very narrow tactical lens while others are looking at the opportunity much more strategically. For many, they are looking at a “care anywhere and everywhere” strategy. From a full “hospital in the home” approach to remote monitoring devices, it is clear that your home will be seen as a venue of care and an access point moving forward. The pandemic of 2020 may have sparked a new era of “post-hospital healthcare” — stay tuned.
5. Bury Your Budget and Pivot to Planning:The budget process has been a source of incredible distrust, dissatisfaction and distraction for every health system for decades. The chaos and uncertainty of the pandemic forced every organization to bury their budget last year. With that said, many of the organizations that presented are now making a permanent shift away from a “budget-based culture” where the focus is on hitting a now irrelevant target set that was set six to nine months ago to a “performance-based culture” where the focus is on making progress every day, week, month and quarter. Given that the traditional annual operating budget process has been the core of how health systems have operated, this shift to a rolling forecast and a more dynamic planning process is likely the single most substantial and permanent change in how hospitals and health systems operate due to COVID. In other words, it is arguably a much bigger headline than what’s happened with virtual visits.
6. Get Your M&A Machine in Motion: It was clear from the presentations that activity around acquisitions is going to return, perhaps significantly. These organizations have strong balance sheets and while the strong have gotten stronger during COVID, the weak have in many cases gotten weaker. Many are going to be opportunistic to acquire hospitals, but at the same time they have concluded that they can’t just be a system of care delivery. They are also focused on acquiring and investing in other types of entities as well as forming more robust partnerships to create new revenue streams. Organizations that already had diversified revenue streams in place came through this pandemic the best. Most hospitals are overly reliant on the ED and surgical volume. Trying to drive that volume in a value-based world, with the end of site of service differentials and the inpatient only list, will be an even bigger challenge in the future as new niche players enter the market. As I wrote in the headline of my summary two years ago, “It’s the platform, stupid.” There are better ways to create a financial path forward that involve leveraging their assets — their platform — in new and creative ways.
7. Hey, You, Get into the Cloud:With apologies for wrapping a Rolling Stones song into a conference summary, one of the main things touted during presentations was “the cloud” and their ability to pull clinical, operational and financial dashboards together to monitor the impact of COVID on their organization and organize their actions. Focus over the last decade has been on the clinical (implementing EHRs), but it is now shifting to “digitizing operations” with a focus on finance and operations (planning, cost accounting, ERPs, etc.) as well as advanced analytics and data science capabilities to automate, gather insight, manage and predict. It is clear that the cloud has moved from a curiosity to a necessity for health systems, making this one of the biggest areas of investment for every health system over the next decade.
8. Make Price Transparency a Key Differentiator: One of the great lessons from Amazon (and others) is that you can make a lot of money when you make something easy to buy. While many health systems are skeptical of the value of the price transparency requirements, those that have a deep understanding of both their true cost of care and margins are using this as an opportunity to prove their value and accelerate their strategy to become consumer-centric. While there is certainly a level of risk, no business has ever been unsuccessful because they made their product easier to understand and access. Because healthcare is so opaque, there is an opening for healthcare providers to build trust, which is their main asset, and volume, which is their main source of revenue, by becoming stunningly easy to do business with. This may be tough sledding for some as this isn’t something healthcare providers are known for. To understand this, spend a few minutes on Tesla’s website vs. Ford’s. The concept of making something easy, or hard, to buy will become crystal clear as fast as a battery-driven car can go from zero to 60.
9. Make Care More Affordable:This represents the biggest challenge for hospitals and health systems as they ultimately need to be on the right side of this issue or the trust that they have will disappear and they will remain very vulnerable to outside players. All are investing in advanced cost accounting systems (time-driven costing, physician costing, supply, and drug costing) to truly understand their cost and use that as a basis to price more strategically in the market. Some are dropping prices for shoppable services and using loss leader strategies to build their brand. The incoming Secretary of Health and Human Services has a strong belief regarding the accountability of health systems to be consumer centric. The health systems that understand this are working to get ahead of this issue as it is likely one of their most significant threats (or opportunities) over the next decade. This means getting all care to the right site of care, evaluating every opportunity to improve, and getting serious about eliminating the need for expensive care through building healthy communities. If you’re worried about Wal-Mart or Amazon, this is your secret weapon to keep them on the sideline.
10. Scale = Survival: One of the big lessons here is that the strong got stronger, the weak got weaker. For the strong, many have been able to “snapback” in financial performance because they were resilient. They were able to designate COVID-only facilities, while keeping others running at a higher capacity. To be clear, while most health systems are going to get to the other side and are positioned better than ever, there are many others that will continue to struggle for years to come. According to our data at Strata, we see 25 percent operating at negative margins right now and another 50 percent just above breakeven. They key to survival moving forward, for those that don’t have a captive market, will be scale. If this pandemic proved one thing relative to the future of health systems it is this — scale equals survival.
When Will We Return to Normal?
Based on what the projections that these health systems shared, the “new normal” for health systems for the first half of 2021 will be roughly 95 percent of prior year inpatient volume with a 20 percent year-over-year drop in ED volume and a drop of 10-15 percent in observation visits. So, the pain will continue, but given the adjustments that were already made in 2020, it looks like they will be able to manage through COVID effectively. While there will be a pickup in the second half of 2021, the safe bet is that a “return to normal” pre-COVID volumes likely won’t occur until 2022. And there are some who believe that some of the volume should have never been there to begin with and we might see a permanent shift downward in ED volume as well as in some other areas.
With that said, I’ll steal a quote from Bert Zimmerli, the CFO of Intermountain Healthcare, who said, “Normal wasn’t ever nearly good enough in healthcare.”In that spirit, the goal should be to not return to normal, but rather to use this moment as an opportunity to take the positive changes driven by COVID — from technology to processes to areas of focus to a sense of responsibility — and make them permanent.
Thanking Our “Healthcare Heroes”
We’ll never see another 2020 again, hopefully. With that said, one of the silver linings of the year is everything we learned in healthcare. The most important lesson was this — in healthcare there are literally heroes everywhere. To each of them, I just want to say “thank you” for being there for us when we needed you the most. We should all be writing love letters to those on the front line who risked their lives to save others. Our nation’s healthcare system has taken a lot of criticism through the years from those on the outside, often with a blind eye to how things work in practice vs. in concept. But this year we all got to see first-hand what’s happening inside of healthcare — the heroic work of our healthcare providers and those who support them.
They faced the worst crisis in the history of healthcare. They responded heroically and were there for our families and friends.
They proved that healthcare is too vital to fail. They proved that healthcare is pandemic-proof.