ACA Section 1332 State Innovation Waivers Update

https://www.healthaffairs.org/do/10.1377/hblog20200729.217545/full/

Tracking Section 1332 State Innovation Waivers | KFF

On July 24, 2020, the Centers for Medicare and Medicaid Services (CMS) and the Treasury Department approved Pennsylvania’s waiver application to operate a state-based reinsurance program under Section 1332 of the Affordable Care Act (ACA). This makes Pennsylvania the thirteenth state to be approved for a state-based reinsurance program. This post also summarizes the newest waiver proposal in Georgia.

Pennsylvania’s Waiver And More On Section 1332 Waivers

In late June, Pennsylvania received federal approval for a five-year reinsurance program beginning with the 2021 plan year. The state’s $139.3 million reinsurance program is expected to reduce premiums by about 4.6 percent (relative to what premiums would have been in the absence of the waiver) and increase enrollment in the individual market by about 0.5 percent in 2021. The federal government will contribute $95.1 million while state funds would account for about $44.2 million.

Implementation of the reinsurance program will coincide with a transition away from the federal marketplace to the new state-based marketplace, the Pennsylvania Health Insurance Exchange (Exchange). Both the reinsurance program and the Exchange were created in the same piece of 2019 legislation, which requires the Exchange to assess and collect fees—up to 3.5 percent of total monthly premiums—to support the reinsurance program. Pennsylvania expects to set the initial user fee at 3 percent of total monthly premiums. Each year, the Exchange will collect the user fee from insurers, deduct its operating expenses, and transfer the remaining funds to a reinsurance fund. In making reinsurance payments to insurers, Pennsylvania intends to first exhaust federal pass-through funding and then user fee revenue.

Based on CMS data, Pennsylvania insurers paid HealthCare.gov user fees of about $98.1 million for 2018 and about $83.1 million for 2019. (CMS has released 2018 and 2019 user fee data for each state that uses HealthCare.gov.) User fees in 2018 and 2019 were set at 3.5 percent of premiums, although the federal user fee was reduced to 3 percent for 2020.

Like nearly all states with reinsurance programs, Pennsylvania will use an overall attachment point model with parameters set annually by the insurance department. For 2021, the program is expected to reimburse insurers for 60 percent of claims between $60,000 and $100,000. To ensure program flexibility, the insurance department can make payments on a pro rata basis if funding is insufficient. Pennsylvania also intends to leverage the EDGE server maintained by CMS to determine how much each insurer is due. (This issue—whether and how states could leverage EDGE server infrastructure for reinsurance—has come up in at least one other state as well.)

Pennsylvania’s waiver application was submitted on February 11 and deemed complete on March 12. Federal regulators received and considered two supportive comments on the state’s application. In an approval letter to Commissioner Jessica Altman on July 24, the Departments laid out specific terms and conditions that the state must accept within 30 days for the waiver to go into effect. Once the waiver is accepted, the Departments will notify Pennsylvania of its amount of pass-through funding for 2021.

With Pennsylvania, 14 states have approved Section 1332 waivers. All but one approved waiver has been for a state-based reinsurance program, and CMS released a report on the effect of the 12 already-established state-based reinsurance programs. The report identifies the funding source for each state, program parameters, the impact on premiums by state and year, insurer participation, and enrollment. The average premium reduction for 2020 across all states was 17.7 percent. New Hampshire may be soon added to this list for 2021: the state’s waiver application was submitted in late April.

Latest On Georgia’s Waiver Application

Georgia submitted a waiver application in late December 2019. As discussed more here, Georgia’s application had two phases: phase one is for a reinsurance program and phase two involves much broader changes to the state’s individual market known as the “Georgia Access” model. Phase one was deemed complete on February 6, and review of phase two was “paused” to Georgia leaders could submit additional information.

Under the original Georgia Access Model, Georgia would have eliminated the use of HealthCare.gov, transitioned consumers to decentralized enrollment through private web-brokers and insurers, established its own subsidy structure, enabled the subsidization of plans that do not comply with all the ACA’s requirements, and capped enrollment if subsidy costs exceed federal and state funds. The proposal was criticized for jeopardizing access to comprehensive coverage and failing to satisfy Section 1332’s statutory guardrails.

About five months after review was “paused,” Georgia modified its waiver application, requesting that its reinsurance program be approved for 2022 (rather than 2021) and abandoning some initial components of phase two. The new waiver application was posted in early July and exposed for public comment until July 23.

The main change for phase two is that Georgia would no longer develop its own state-specific subsidy structure. Georgia would validate a consumer’s eligibility for premium tax credits and then send this information to the federal government. The federal government would then issue the subsidies to insurers and reconcile subsidies during tax season. Subsidies would only be available for qualified health plans under the ACA, as they are now. But Georgia wants to conduct its own eligibility determinations because it believes doing so will be more accurate: the state can leverage existing infrastructure, use more recent employment data, and integrate Medicaid eligibility determinations.

The waiver would, however, still eliminate the use of HealthCare.gov, which would make Georgia the only state to do so. Marketplace consumers would be forced to transition to a highly decentralized enrollment system that uses web-brokers and insurers. As a summary of the revised application puts it, Georgia will “transition responsibility for front-end functions of consumer outreach, customer service, plan shopping, selection, and enrollment from the [federal marketplace] to the commercial market.”

While federal subsidies could not be used towards non-ACA plans, Georgia continues to note that a benefit of moving away from HealthCare.gov to web-brokers and insurers is that residents could “view the full range of health plans” offered in the state. Georgia would leverage enhanced direct enrollment (EDE) standards which, as discussed more below, can lead to significant consumer confusion.

From here, Georgia will presumably respond to the latest round of public comment on its new proposal and then submit its revised application.

 

The COVID-19 Downturn Triggers Jump in Medicaid Enrollment

The COVID-19 Downturn Triggers Jump in Medicaid Enrollment

Reversing a three-year decline, the number of people covered by Medicaid nationwide rose markedly this spring as the impact of the recession caused by the outbreak of COVID-19 began to take hold.

Yet, the growth in participation in the state-federal health insurance program for low-income people was less than many analysts predicted. One possible factor tempering enrollment: People with concerns about catching the coronavirus avoided seeking care and figured they didn’t need the coverage.

Program sign-ups are widely expected to accelerate through the summer, reflecting the higher number of unemployed. As people lose their jobs, many often are left without workplace coverage or the money to buy insurance on their own.

Medicaid enrollment was 72.3 million in April, up from 71.5 million in March and 71 million in February, according to the latest enrollment figures released last week by the Centers for Medicare & Medicaid Services. The increase in March was the first enrollment uptick since March 2017.

About half of the people enrolled in Medicaid are children.

The increases varied widely around the country. Kentucky had the largest jump at nearly 7% from March to April. In addition, enrollment rose to 1.4 million in April from 1.2 million in February, according to the CMS data. That has continued, and today it’s up to 1.5 million, state officials said in an interview.

Kentucky has an aggressive outreach strategy using email or phone calls to contact thousands of residents who applied for state unemployment insurance, designed to make sure they know about Medicaid. “It’s been very effective, and in the past few weeks we’ve been enrolling 8,000 to 10,000 people a week,” said Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services, which oversees Medicaid.

The Bluegrass State has also made enrollment easier by developing a one-page online form instead of having people fill out a 20-page application, he added.

“This is the right thing to do to help people get signed up for health care coverage and it supports the health industry in our state,” Friedlander said. “The health industry would collapse without Medicaid.”

Joan Alker, executive director of the Center for Children and Families at Georgetown University in Washington, D.C., said she expects Medicaid enrollment to keep rising this summer. “Given that there are no signs that the virus is coming under control anytime soon, job losses will become more permanent, and more folks will become eligible for Medicaid over time,” she said.

One reason Medicaid numbers have not grown faster, she suggested, is because people have more immediate needs than securing health coverage, especially if they are feeling well.

Many people are worried about getting unemployment insurance or getting evicted from their home, she noted. “That’s combined with the fact that many people are reluctant to go to their doctor because of safety concerns,” she said. “And, as a consequence, applying for Medicaid may not be at the top of their list.”

Chris Pope, a senior fellow at the Manhattan Institute for Policy Research, a conservative think tank, said the slower-than-expected growth in Medicaid could signal that people who were laid off had coverage through a spouse or a parent.

In addition, he said, “many jobs that went away did not offer health insurance,” citing millions of service-sector positions in industries such as hotels and restaurants that have been lost.

Beyond the surge in unemployment, Medicaid rolls have risen because states cannot discontinue coverage to people enrolled as of March 18, 2020, as a condition of receiving higher federal Medicaid funding included in a coronavirus relief package passed by Congress.

Medicaid is a countercyclical program, meaning enrollment typically rises during an economic downturn. But that forces states to face the fiscal challenge of paying for their share of the program even as tax revenue dries up.

An exception to this rule was the jump in enrollment starting in 2014 when the Affordable Care Act allowed states to expand Medicaid to cover everyone with incomes below 138% of the federal poverty level, or about $17,609 for an individual this year.

Enrollment soared by about 15 million people from 2014 to 2017, peaking at about 75 million as nearly three dozen states expanded the program. Since then, a strong economy and steadily declining unemployment levels led to a drop in Medicaid rolls until April.

Enrollment changes in April varied across the country.

California, which has the highest Medicaid enrollment in the country, saw its level hold relatively steady at 11.6 million people in April.

Nevada and Oklahoma posted nearly 4% enrollment growth rates between March and April’s data.

Florida’s Medicaid numbers jumped to 3.7 million in April from 3.6 million in March, nearly a 2.5% increase, the CMS data showed. Since then, Florida data shows enrollment has topped 4.1 million.

The Trump administration has been criticized by consumer advocates for not establishing a national campaign to promote Medicaid during the economic downturn and health crisis.

One indicator that Medicaid enrollment is still going up is the growing number of recipients in managed care plans in 16 states that reported data from March to May. Those plans have increased by a total of nearly 4%, according to a KFF report. (KHN is an editorially independent program of KFF.) Most states have shifted many of their Medicaid enrollees into these private health plans.

KFF estimated that nearly 13 million people who became uninsured after losing their jobs in March are eligible for Medicaid.

Robin Rudowitz, a KFF vice president, said there is typically a lag time of weeks or months before people who have lost their jobs and health coverage seek to enroll in Medicaid. The impact on Medicaid enrollment also lasts well after the immediate effect of a downturn, she said.

“There is a long tail,” she said.

 

 

 

 

 

KHN’s ‘What The Health?’: Trump Twists on Virus Response

KHN’s ‘What The Health?’: Trump Twists on Virus Response

KHN's 'What The Health?': Trump Twists on Virus Response | Kaiser ...

President Donald Trump — who has spent the past six months trying to play down the coronavirus pandemic — seems to have pivoted. In back-to-back briefings on July 21 and 22, Trump cautioned that the U.S. is in a dangerous place vis-a-vis the pandemic. He urged the public to wear masks — although he has rarely worn one in public.

Meanwhile, Republicans in the Senate are scrambling to put together a package for the next COVID-19 relief bill, facing a July 31 deadline, when some of the benefits passed in the spring expire. House Democrats passed their bill in May.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Tami Luhby of CNN.

Among the takeaways from this week’s podcast:

  • Although Trump’s renewed emphasis on COVID-19 has surprised some of his critics, it may persuade his supporters to take actions promoted by public health officials. Trump’s emphasis on the importance of face coverings, perhaps coupled with the rising number of cases in parts of the country, could convince people who were otherwise dismissive of masks. People who do not necessarily trust public health officials may listen to Trump.
  • Republicans on Capitol Hill are in disarray on how to approach the next coronavirus relief bill. They are not in lockstep with the White House and are not supporting Trump’s call for a payroll tax cut.
  • One reason members of Congress are not eager to cut the payroll taxes is that the economic downturn has spurred concerns the Medicare and Social Security trust funds are being depleted faster than expected. However, analysts point out that when employment rises again, some of those concerns could dissipate.
  • A key sticking point in the economic relief package is whether to extend the bump in unemployment benefits that Congress approved in the spring. Lawmakers are facing a hard deadline on the issue because that money runs out next week, and the prohibition on evictions that was also part of an earlier COVID-19 relief bill ends even sooner. With rent, mortgages and other bills coming due Aug. 1, unemployed consumers could face a tough beginning of the month.
  • The Food and Drug Administration has approved limited use of pool testing for COVID-19. That allows approved labs to put together a small number of tests to run at once, thus conserving some of the materials needed for the process. If the pool tests positive, then those people whose results were pooled have to be tested again individually. The efforts have limited usefulness when rates of transmission are high in a community, but they may be helpful in specific settings, such as schools or workplaces.
  • New data shows that opioid addiction ticked back up in 2019, after a slight decline. Part of the problem is the growing use of the powerful — and dangerous — drug fentanyl. Economic woes also play a role. Addiction is often referred to as an epidemic of despair.
  • Although it’s unlikely the judicial system will overrule the administration’s efforts to bolster short-term insurance plans — which are generally less expensive but don’t offer as much protection for consumers as policies sold on the Affordable Care Act’s marketplaces — they could be circumvented if Democrats take over the White House. Even still, Democrats would likely have to find a way to make ACA plans more affordable.

 

 

 

 

 

Increasing unemployment alters national payer mix

https://mailchi.mp/9075526b5806/the-weekly-gist-july-24-2020?e=d1e747d2d8

 

One in every five workers is now collecting unemployment benefits as the country struggles to get the COVID-19 outbreak under control. A recent Families USA study estimates a quarter of the 21.9M workers that were furloughed or laid off between February and May lost their health insurance. And the payer mix will continue to change as the pandemic wears on.

The graphic below highlights a study from consultancy Oliver Wyman, looking at the impact of rising unemployment (at 15, 20 and 30 percent) on insurance coverage. With each five to ten percent rise in unemployment, the commercially insured population decreases by three to five percentThose who lose employer-sponsored insurance either remain uninsured, buy coverage on the Obamacare marketplaces, or qualify for Medicaid.

Surprisingly, Washington State and California are reporting little to no enrollment growth in Medicaid programs thus far. Experts point to lack of outreach and consumer awareness as key contributors to the slow growth—but Medicaid enrollment will likely begin to rise quickly in coming months as temporary furloughs convert to more permanent layoffs.

The right side of the graphic spotlights the growing number of uninsured individuals in those states with the highest uninsured rates. The previous record for the largest increase in uninsured adults was between 2008 and 2009, when nearly 4M lost coverage. The current pandemic-driven increase has crushed that record by 39 percent.

On average, states are seeing uninsured populations increase by two percent, with some as high as five percent. And the two states with the highest uninsured rates, Florida and Texas, are also dealing with the largest surge in COVID-19 cases and deaths. The ranks of the uninsured will continue to climb as states reimpose shutdowns, government assistance ends, and layoffs grow.

 

 

Why COVID-19’s biggest impact on healthcare may not be until 2022

https://www.healthcaredive.com/news/why-covid-19s-biggest-impact-on-healthcare-may-not-be-until-2022/582129/

This perfect storm of a shift in payer mix, the impending insolvency of Medicare and the inability of states to absorb the growing costs of Medicaid represent a tsunami of challenges.

With COVID-19 there has been unprecedented stress placed upon the healthcare system. The human and financial toll of the current crisis has been extraordinary. Yet, little attention has been focused on the impact of this virus on the viability of our healthcare financing system.

Three significant shifts in healthcare financing are occurring as a result of the pandemic’s economic impact. First, as a result of job losses, there will be a shift in commercial insurance to government-funded insurance programs. Second, revenue for funding Medicare, based on payroll taxes, will be significantly decreased. Finally, states will have less tax revenue to pay for Medicaid, threatening the viability of this program as well.

More than 30 million Americans have filed for unemployment since the start of the COVID-19 pandemic. According to a recent report, about 27 million people may lose their employer-sponsored insurance. 

This will result in millions of people seeking coverage through Medicaid programs, the individual marketplace or simply becoming uninsured. Healthcare providers have relied upon margins from commercial insurance to offset costs from poorer reimbursing government funded programs and uncompensated care.

With more than 156 million Americans receiving employer sponsored insurance at the start of this year, and given recent projected job losses, providers may see a 17% shift in payer mix. The reliance on commercial insurance and cost shifting has become a necessary way for providers to financially sustain operations. 

With a 35% margin with commercial insurance compared to Medicare, a 17% shift in payer mix on a trillion dollar spend would result in a substantial reduction in financial resources available to hospitals.

Almost half of healthcare expenditures already come from government programs. Medicare, the largest of these programs, is principally supported by taxes on payroll and social security benefits. With COVID-related job losses there will be a corresponding reduction in payroll tax revenues to the Medicare system. Reports from the Congressional Research Service submitted to Congress in May, with data used prior to COVID-19, projected that Medicare would become insolvent in 2026.

Analyses performed show that there will be a gap in Medicare revenues during the next three years (from the pre-COVID projections) of close to $150 billion. The result is that Medicare will become insolvent as early as 2022. Even by applying more conservative projections, such as recovering all job losses by the end of 2020 and payroll tax revenue holding steady at pre-COVID levels, Medicare still becomes insolvent in 2023.

State revenues, too, will be under real pressure with reduced tax revenues resulting from the current economic downturn. Medicaid programs are supported in part by federal funds, but also from general funds from the state. 
On average, states are projecting about a 10% reduction in revenues in 2020, rising to almost a 25% reduction in 2021. Even without considering the growth in Medicaid enrollment hitting states, this reduced tax revenue will make sustaining current Medicaid program funding increasingly difficult.

This perfect storm of a shift in payer mix, the impending insolvency of Medicare by 2022 and the inability of states to absorb the growing costs of Medicaid represent a tsunami of challenges for the health system. Looking at this new reality, it is clear that our system for financing healthcare is severely broken and we must identify solutions to sustain access to medical care for our citizens.

This will be a challenge of a generation and we will need strength, courage and bold ideas to get through this. Pandemics have a way of changing a society’s political, economic and sociologic outlooks, and COVID-19 will be no different. 

 

 

 

How the coronavirus pandemic became Florida’s perfect storm

https://theconversation.com/how-the-coronavirus-pandemic-became-floridas-perfect-storm-142333

How the coronavirus pandemic became Florida's perfect storm

If there’s one state in the U.S. where you don’t want a pandemic, it’s Florida. Florida is an international crossroads, a magnet for tourists and retirees, and its population is older, sicker and more likely to be exposed to COVID-19 on the job than the country as a whole.

When the coronavirus struck, the conditions there made it a perfect storm.

Florida set a single-day record for new COVID-19 cases in early July, passing 15,000 and rivaling New York’s worst day at the height of the pandemic there. The state has become an epicenter for the spread, with over 300,000 confirmed cases. Its hospital capacity is under stress, and the death toll has been rising.

Despite these strains, Disney World reopened two theme parks on July 11, and Florida Gov. Ron DeSantis announced schools would reopen in August. The governor had shut down alcohol sales in bars in late June as case numbers skyrocketed, but he hasn’t made face masks mandatory or moved to shut down other businesses where the virus can easily spread.

As public health researchers, we have been studying how states respond to the pandemic. Florida stands out, both for its absence of statewide policies that could have stemmed the spread of COVID-19 and for some unique challenges that make those policies both more necessary and more difficult to implement than in many other states.

The challenges of economic pressures

Florida is one of nine states with no income tax on wages, so its tax base relies heavily on tourism and property in its high-density coastal areas. That puts more pressure on the government to keep businesses and social venues open longer and reopen them faster after shutdowns.

If you look closely at Florida’s economy, its vulnerabilities to the pandemic become evident.

The state depends on international trade, tourism and agriculture – sectors that rely heavily on lower-wage, often seasonal, workers. These workers can’t do their jobs from home, and they face financial barriers to getting tested, unless it’s provided through their employer or government testing sites. They also struggle with health care – Florida has a higher-than-average rate of people without health insurance, and it chose not to expand Medicaid.

In the tourism industry, even young, healthy employees typically at lower risk from COVID-19 can unknowingly spread the virus to visitors or vice versa. The tourism industry also encourages crowded bar and club scenes, where the governor has blamed young people for spreading the coronavirus.

The past few weeks have been emblematic of the economic battles facing a state that depends on tourism for both jobs and state revenues.

Even as the public health risks were quickly rising, businesses continued to open their doors. Major cruise lines planned to resume their itineraries in the fall. A note on the Universal Studios website read: “Exposure to COVID-19 is an inherent risk in any public location where people are present; we cannot guarantee you will not be exposed during your visit.”

Disney World reopened on July 11 with face mask requirements. Matt Stroshane via Disney

Reopening guidance has been largely ignored

The Governor’s Re-open Florida Taskforce issued guidelines in late April meant to lower the state’s coronavirus risk, but those guidelines have been largely ignored in practice.

No county in Florida has reduced cases or maintained the health care resources recommended by the task force. The data needed to fully assess progress are also questionable, given a recent scandal regarding the state data’s accuracy, availability and transparency.

Still, the coronavirus’s rapid surge in Florida is evident in the state-reported casesTesting lines are long, and almost 1 in 5 tests have been positive for COVID-19, suggesting the prevalence of infections is still increasing.

Florida’s patchwork of local rules also makes it hard to contain the virus’s spread.

With no statewide mask rules or plans to reverse reopeningother than for bars, communities and businesses have taken their own actions to implement public health precautions. The result is varying mask ordinances and restrictions on large gatherings in some cities but not those surrounding them. Though the Florida Department of Health has issued an advisory recommending face coverings, some local areas have voted down mask mandates.

More warning signs ahead

Late summer and fall will bring new challenges for Florida in terms of the virus’s spread and the state’s response to it.

That’s when Florida’s risk of hurricanes grows, and while Floridians are well-versed in hurricane preparedness, storm shelters aren’t designed for social distancing and will need careful plans for protecting nursing home residents. Storm cleanup could mean lots of people working in close proximity while protective gear is in short supply.

If Florida’s schools reopen fully, the risk of the virus rapidly spreading to teachers, parents and children who are more vulnerable is a real concern being weighed against the costs of keeping schools closed.

Colleges that reopen to classes and sporting events also raise the risk of spreading the virus in Florida communities. And the possible return of retirees who spend their winters in Florida would increase the high-risk population by late fall. One in five Florida residents is over age 65, giving the state one of the nation’s oldest populations – a risk factor, along with chronic illnesses, for severe symptoms with COVID-19.

Florida is also a battleground state for the upcoming presidential election, and that’s likely to mean campaign rallies and more close contact. The Republican National Convention was moved to Jacksonville after President Donald Trump complained that North Carolina might not let the GOP fill a Charlotte arena to capacity due to coronavirus restrictions. Florida organizers recently said they were considering holding parts of the convention outdoors.

The high number of cases being reported in Florida will lead to even more hospitalizations and fatalities in coming weeks and months. Without clear public health messages and precautions implemented and enforced across the state, the coronavirus forecast for the Sunshine State will remain stormy.

 

 

 

Texas has the highest uninsured rate in the U.S., with 29 percent of adults uninsured as of May

https://www.beckershospitalreview.com/rankings-and-ratings/states-ranked-by-uninsured-rates.html?utm_medium=email

COVID-19 Health: Rate of Uninsured Americans by City - Self

Texas has the highest uninsured rate in the U.S., with 29 percent of adults uninsured as of May, according to a report from Families USA. 

The report compared uninsured rates in 2018 to rates in May 2020 using data from the U.S. Bureau of Labor Statistics and the Urban Institute. Every state saw an increase in the number of uninsured, and the total number of uninsured in the U.S. climbed 21 percent.

The increase was due in part to layoffs tied to the COVID-19 pandemic in recent months. Nearly 5.4 million Americans lost health insurance coverage from February to May of this year due to job losses, according to the report.

Below is the total percentage of all uninsured adults in each state and the District of Columbia as of May. 

Texas: 29 percent

Florida: 25 percent

Oklahoma: 24 percent

Georgia: 23 percent

Mississippi: 22 percent

Nevada: 21 percent

North Carolina: 20 percent

South Carolina: 20 percent

Alabama: 19 percent

Tennessee: 19 percent

Idaho: 18 percent

Alaska: 17 percent

Arizona: 17 percent

Missouri: 17 percent

Wyoming: 17 percent

New Mexico: 16 percent

South Dakota: 16 percent

Arkansas: 15 percent

Kansas: 15 percent

Louisiana: 14 percent

Virginia: 14 percent

California: 13 percent

Colorado: 13 percent

Illinois: 13 percent

Indiana: 13 percent

Maine: 13 percent

Montana: 13 percent

New Jersey: 13 percent

Oregon: 13 percent

Utah: 13 percent

Michigan: 12 percent

Nebraska: 12 percent

Washington: 12 percent

West Virginia: 12 percent

Delaware: 11 percent

Maryland: 11 percent

New Hampshire: 11 percent

North Dakota: 11 percent

Ohio: 11 percent

Connecticut: 10 percent

Hawaii: 10 percent

Kentucky: 10 percent

New York: 10 percent

Pennsylvania: 10 percent

Wisconsin: 10 percent

Iowa: 9 percent

Rhode Island: 9 percent

Massachusetts: 8 percent

Minnesota: 8 percent

Vermont: 7 percent

District of Columbia: 6 percent

 

 

GOP senators in close races mislead on preexisting conditions

https://www.washingtonpost.com/politics/2020/07/15/gop-senators-close-races-mislead-preexisting-conditions/?utm_campaign=wp_main&utm_medium=social&utm_source=facebook&fbclid=IwAR3XOi91b1jsLf-grP_iIXALJiIvlZNItPE1ZDO0_ql4Wlw8m3GicyoHIH8

2018 midterms: Republicans mislead voters about preexisting ...

“Steve Daines will protect Montanans with preexisting conditions.”

“Of course I will always protect those with preexisting conditions. Always.”

“What I look forward to working on is a plan that protects people with preexisting conditions.”

— Sen. Cory Gardner (R-Colo.), in an interview with Colorado Public Radio, July 1, 2020

 

Sound familiar? Just like President Trump, these Republican senators say they support coverage guarantees for patients with preexisting health conditions. And just like Trump, their records show the opposite.

The president’s doublespeak — voicing support for these protections while asking the Supreme Court to strike them down — is spreading into some battleground Senate races this year.

 

It’s a classic case of buyer beware: Look under the hood of what Daines, Gardner and McSally are selling, and you’ll find a car without an engine.

THE FACTS

Republicans for a decade have tried to repeal the Affordable Care Act, President Barack Obama’s signature health-care legislation. The Supreme Court has upheld the law twice in the face of challenges from conservative groups. As coronavirus cases reached a new high in the United States, the Trump administration filed a legal brief on June 25 asking the Supreme Court to strike down the entire law, joining with a group of GOP state attorneys general who argue that the ACA is unconstitutional.

Before the ACA, insurance companies could factor in a person’s health status while setting premiums, a practice that sometimes made coverage unaffordable or unavailable for those in need of expensive treatment or facing a serious illness such as cancer.

 

The ACA PROHIBITED THIS PRACTICE through two provisions: “guaranteed issue,” which means insurance companies must sell insurance to anyone who wants it, and “community rating,” which means people in the same age group and geographic area who buy similar insurance pay similar prices. The changes made insurance affordable for people with serious diseases or even those with minor health problems, who also could have been denied coverage before the law’s passage.

Now, about 20 million people covered through the ACA could lose their health insurance if the Supreme Court strikes down the law, among many other consequences bearing directly on the U.S. response to the coronavirus pandemic.

In addition to the coverage guarantee, the ACA established online health insurance marketplaces and subsidies for participating buyers. The law also directs billions of dollars a year in federal funding to states that have chosen to expand their Medicaid programs under the Obamacare law. Millions of Americans have gained coverage through those provisions.

We asked the Daines, Gardner and McSally campaigns whether the senators support or oppose the GOP lawsuit at the Supreme Court and how they would address affordability issues for patients with preexisting conditions if the ACA falls. None of their campaigns responded to our questions.

 

“Steve Daines will protect Montanans with preexisting conditions.”

Daines voted to repeal the ACA in 2013 and has supported efforts to repeal and replace the law more recently during the Trump administration.

Regarding the GOP lawsuit, a Daines spokesperson was quoted in the Billings Gazette saying the senator “supports whatever mechanism will protect Montanans from this failed law, lower health care costs, protect those with preexisting conditions and expand access to health care for Montanans.”

 

“What I look forward to working on is a plan that protects people with preexisting conditions.” (Gardner)

Gardner has been voting to repeal, defund or replace the ACA since 2011, the year after its passage. This year, his campaign website says nothing about the law, but his official Senate website says, “Fixing our healthcare system will require repealing the Affordable Care Act and replacing it with patient-centered solutions, which empower Americans and their doctors.”

Asked by the Hill whether he supported the GOP lawsuit, Gardner said: “That’s the court’s decision. If the Democrats want to stand for an unconstitutional law, I guess that’s their choice.” In an interview with Colorado Public Radio, Gardner evaded the question six times in a row.

“Of course I will always protect those with preexisting conditions. Always.” (McSally)

In 2015, McSally voted to repeal the ACA when she served in the House. In 2017, she voted to replace the ACA with the American Health Care Act, which would have allowed insurers to charge higher premiums to patients with complicated medical histories.

McSally, now in the Senate, has declined to comment on the GOP lawsuit pending before the Supreme Court. When asked by PolitiFact, “the campaign didn’t specifically answer, but pointed to her general disapproval of the ACA.”

WHAT HAPPENS IF  THE GOP LAWSUIT SUCCEEDS?

Trump told The Washington Post days before his inauguration in 2017 that he was nearly done with his plan to replace the ACA. Three and a half years later, no replacement plan has emerged from the administration and Republicans in Congress hardly agree on what it would look like — or how to preserve the protections for preexisting health conditions.

Sen. Thom Tillis (R-N.C.), who is also running for reelection this year, has introduced a 24-page bill called the Protect Act that includes language guaranteeing coverage for preexisting conditions. Daines signed on as a co-sponsor on June 24, the day before the Justice Department filed its brief in the Supreme Court. McSally signed on in April 2019. Gardner is not listed as a co-sponsor.

Experts say the Tillis proposal does not offer the same level of protection for preexisting conditions as the ACA, and they warn that millions of Americans could lose their health coverage if the ACA falls and the Protect Act is the only replacement.

“Insurers before the Affordable Care Act had multiple and redundant ways that they could avoid people who had preexisting conditions,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. The Protect Act prevents some of those practices, but it “leaves enough other loopholes that it would make it very possible and likely for insurers to be able to avoid paying benefits for the conditions they most worry about,” she said.

 

Before the ACA, an insurance company could reject an application outright, say, after reviewing a patient’s medical history. The Protect Act has language barring that practice.

“The second thing they could do is, they could sell you coverage, but they could exclude your preexisting condition. ‘Oh, you have diabetes? I’m not going to pay for any of those benefits,’” Pollitz said. “The Tillis bill says you can’t do that, so that’s good.”

In the days before the ACA, insurers were allowed to charge higher premiums based on a patient’s health status. To prevent this, the Protect Act takes language from the Health Insurance Portability and Accountability Act (HIPAA), rather than the newer ACA.

“The Protect Act inserts old HIPAA nondiscrimination language that prevents employers from varying worker premium contributions based on health status,” Pollitz said. “But the Protect Act also includes the old rule of construction that says nothing limits what the insurance company can charge the employer or individual.”

Pollitz said the “community rating” language in the ACA provides clearer protections in this area. The Protect Act says “nothing … shall be construed to restrict the amount that an employer or individual may be charged for coverage under a group health plan.”

“The bill would reinstate three protections at risk in the Texas case — prohibiting insurers from denying applicants based on pre-existing conditions, charging higher premiums due to a person’s health status, and excluding pre-existing conditions from coverage,” Sarah Lueck, a senior policy analyst at the left-leaning Center on Budget and Policy Priorities, wrote in an analysis.

“But it would leave many others on the cutting room floor,” she wrote, because insurers would be able to exclude coverage of benefits such as maternity care, mental health and substance-use treatment; set annual and lifetime limits on insurance payouts; and charge older patients more than younger patients at greater levels than the ACA allows, among other changes.

It’s important to keep in mind that the Protect Act would not replace other parts of Obamacare, such as the online marketplaces and subsidies. Neither would it continue the ACA’s Medicaid expansion, which 37 states and D.C. have now adopted. That includes Arizona, Colorado and Montana.

 

The Pinocchio Test

Voters deserve straight answers when their health care is on the line, especially in the middle of a deadly pandemic.

Daines, Gardner and McSally have voted to end the Affordable Care Act. People with preexisting conditions would have been left exposed because of those votes; insurers could have denied coverage or jacked up prices for sick patients.

The three senators’ comments about the GOP lawsuit are woefully vague, but they can all be interpreted as tacit support. Asked about the case, a Daines spokesperson said “whatever mechanism” to get rid of the ACA would do. McSally’s campaign “didn’t specifically answer, but pointed to her general disapproval of the ACA.” Gardner avoided the question six times in one interview, but in another, he said: “That’s the court’s decision. If the Democrats want to stand for an unconstitutional law, I guess that’s their choice.”

Four Pinocchios all around.

 

 

 

 

Democrats align around a health policy platform

https://mailchi.mp/86e2f0f0290d/the-weekly-gist-july-10-2020?e=d1e747d2d8

Abstract Word Cloud For Health Policy With Related Tags And Terms ...

 

Promising that “we are going to at last build the health care system the American people have always deserved”, a joint task force of health policy advisors from the Biden and Sanders campaigns this week released a unified set of proposals that will serve as part of the former Vice President’s campaign platform for the November election.

While the document does not include Sanders’ signature “Medicare for All” proposal, it does support a government-run public insurance option that would be available to all Americans, at income-adjusted, subsidized rates—including free coverage for those with low incomes. It also promises to expand Medicare benefits to include dental, vision, and hearing coverage, and to extend Medicare eligibility to those age 60 and above.

For those who lose their health coverage due to the COVID pandemic, the unity document endorses having the government pick up the tab for COBRA benefits and shifting enrollees into premium-free coverage on the Obamacare exchanges when their COBRA eligibility expires.

It also promises greater investment in public health resources, including increased funding for the CDC, and funding to recruit 100,000 contact tracers nationwide.

Other key components of the proposal include eliminating “surprise billing”, reducing drug costs, addressing racial and gender-based health inequities, and bolstering investment in scientific research.

This week’s document represents an important step in unifying the progressive and moderate wings of the Democratic party around key health policy principles. Should Biden win in November, and if Democrats gain control of the Senate, we’d expect quick action on many of these proposals.

Clearly the most difficult would be the public option and Medicare expansion, which would require lengthy negotiation with various industry groups to garner sufficient political support. Similar to the 2009 process that led to the Affordable Care Act, we would likely see a year’s worth of political horse-trading, leading to passage of some compromise legislation before the midterm elections in 2022.

All of that in the midst of an ongoing pandemic and likely prolonged economic downturn—both of which will probably allow for the passage of more far-reaching legislation than might otherwise be possible.

 

 

Canada’s “national shame”: Covid-19 in nursing homes

https://www.vox.com/future-perfect/2020/7/7/21300521/canada-covid-19-nursing-homes-long-term-care

Why Canada's coronavirus cases are concentrated in nursing homes - Vox

Nursing homes account for 81 percent of Covid-19 deaths in the country. How did this happen?

Canada’s response to the coronavirus pandemic has generally been viewed as a success, with experts pointing to its political leadership and universal health care system as factors.

But there has been one glaring failure in Canada’s fight against the pandemic: its inability to protect the health of its senior citizens in nursing homes and long-term care facilities.

The situation for these seniors is so dire that the police — and even the military — have been called in to investigate why so many are dying.

In Quebec, some residents have been left for days in soiled diapers, going hungry and thirsty, and 31 residents were found dead at one home in less than a month, leading to accusations of gross negligence. In Ontario, the military found shocking conditions in five homes: cockroaches and rotten food, blatant disregard for infection control measures, and treatment of residents that was deemed “borderline abusive, if not abusive.”

“It’s a national shame,” said Nathan Stall, a geriatrician at Toronto’s Sinai Health System. “I don’t think we’ve done a good job at all in Canada.”

A whopping 81 percent of the country’s coronavirus deaths are linked to nursing homes and long-term care facilities. That means roughly 7,050 out of 8,700 deaths to date have been among residents and workers in these facilities.

In terms of raw numbers, that may not seem like very much. (For comparison, more than 40,000 US coronavirus deaths have been linked to nursing homes.) And, to be clear, Canada is hardly alone in watching tragedy unfold in these facilities. The US and Europe have seen startling numbers of fatalities among nursing home staffers and residents.

But 81 percent is a staggering statistic, especially for Canada, a country that prides itself on its progressive health policies. And it’s higher than the rate in any other country for which we have good data. In European countries, roughly 50 percent of coronavirus deaths are linked to these facilities. In the US, it’s 40 percent.

Experts say a number of factors are probably involved in Canada’s collapse on the nursing home front, like the fact that Canada has done well at controlling community spread outside these facilities (making nursing home deaths account for a greater share of overall deaths) and that residents in Canadian homes tend to be older and frailer than those in US homes (and thus more vulnerable to severe cases of Covid-19). But they say the high death rate in the homes is due, in large part, to egregious problems with the homes themselves.

“I think we have serious issues with long-term care,” said Vivian Stamatopoulos, a professor at Ontario Tech University who specializes in family caregiving. Experts have been warning political leaders about this for years, but, she said, “they’ve all been playing the game of pass the long-term care hot potato.”

Furious over how their elders are being treated, some Canadians have started petitions, protests, lawsuits, and even hunger strikes outside the homes. They say the government’s failure to respond reveals a deeper failure to care about seniors and people with disabilities, and to make that care concrete by sending facilities what they urgently need: more tests, more personal protective equipment (PPE), and more funding to pay staff members so they don’t have to work multiple jobs at different facilities.

Prime Minister Justin Trudeau has acknowledged that the situation in the facilities is “deeply disturbing.” He’s sent hundreds of military troops to help feed and care for the seniors in certain homes, where burnout and fear have prompted some staff members to flee their charges. But to some extent, Trudeau’s hands are tied because the facilities fall under provincial jurisdiction.

That leaves families terrified for their loved ones. They’re asking: Why have things gone so terribly wrong? How could this happen in Canada?

 

Canada’s crisis was a long time in the making

The first thing to understand is that Canada’s universal health care system does not cover nursing homes and long-term care facilities. That means these institutions are not insured by the federal system. Different provinces offer different levels of cost coverage, and even within a given province, you’ll find that some homes are publicly run, others are run by nonprofits, and still others are run by for-profit entities.

“This is the main problem — they don’t fall under the Canada Health Act,” said Stamatopoulos, adding that the same is not true of hospitals. “That’s why you see that the hospitals did so well. They had the resources.”

From the standpoint of someone in the US, where more than 132,000 people have died of Covid-19, Canada may seem to be doing well overall: The death toll there is around 8,700. Per capita, Canada’s coronavirus death rate is roughly half that of America’s. It’s clear that the northern neighbor has been doing better at keeping case numbers down, partly because it’s giving safer advice on easing social distancing.

Which makes the dire situation in nursing homes stand out even more. Longstanding problems with Canada’s nursing homes have clearly fueled the tragic situation unfolding there.

These homes are chronically understaffed. They tend to hire part-time workers, underpay them, and not offer them sick leave benefits. That means the workers have to take multiple jobs at different facilities, potentially spreading the virus between them. Many are immigrants or asylum seekers, and they fear putting their precarious employment at risk by, say, taking a sick day when they need it. (These problems aren’t unique to Canada, but as in other countries, they’ve been thrown into stark relief by the pandemic.)

A lot of Canadian homes also have poor infrastructure, built to the outdated design standards of the 1970s. Residents often live four to a room, share a bathroom, and congregate in crowded common spaces. That makes it very difficult to isolate those who get sick.

These problems are even worse in Canada’s for-profit nursing homes. Research shows that these private facilities provide inferior care for seniors compared to the public facilities, in large part because they hire fewer staff members and put fewer resources into upgrading or redesigning their buildings. The for-profit model incentivizes cost-cutting. (Similarly problematic profit motives and poor living conditions persist in US nursing homes, too.)

Canadian experts have been raising the alarm about these issues for more than a decade. So why haven’t they been addressed?

“Frankly, overall, it really reflects ageism in society. We choose not to invest in frail older adults,” Stall said. He added that early on in the pandemic, the public imagination latched onto stories of relatively young people on ventilators in hospitals. The hospitals and their staff got resources, free food, nightly applause. Homes for older people didn’t get the same attention.

“Nursing homes are not something we’re proud of societally. There’s a lot of shame around even having someone in a nursing home,” Stall said.

Stamatopoulos noted there are other forces at play, too. “I’d say it’s a trifecta of ageism, racism, and sexism,” she said. “When you look at this industry, it’s majority female older residents being cared for by majority racialized women.”

Ronnie Cahana, a 66-year-old rabbi who lives with paralysis at the Maimonides Geriatric Centre in Montreal, recently wrote a letter to Quebec’s premier. “I am not a statistic. I am a fully sentient, confident human being, who needs to have my humanity honored,” he wrote, adding that the premier should help the workers who take care of people like him. “Many of them are immigrants, newly beginning their lives in Quebec. … Please give them all the resources they require. Listen to their voices.”

 

How to make nursing homes safer — in Canada and beyond

If you want to keep nursing homes from becoming coronavirus hot spots, look to the strategies that have proven effective elsewhere. For months now, Canadian public health experts and advocates have been begging leaders to do just that.

All residents and workers in nursing homes should be tested regularly, whether they show symptoms or not. Anyone who gets sick should be isolated in a separate part of the building or taken to the hospital. Workers should be given adequate PPE, and universal masking among them should be mandatory. Working at multiple homes during the pandemic should be disallowed.

“Look at South Korea. They’ve had no deaths in long-term care because they treated it like SARS right from the get-go,” Stamatopoulos said. “They did aggressive testing. They were strict in terms of quarantining any infected residents and were quick to move them to hospitals. We’ve done the opposite.” Earlier in the pandemic, some Canadian hospitals sent recovering Covid-19 patients back to their nursing homes too soon; they inadvertently infected others.

“And look at New York state,” Stamatopoulos continued. “Gov. Cuomo signed an executive order on May 10 requiring all staff and residents to be tested twice a week. That aggressive testing helped halt the outbreaks in the homes.” Quebec and Ontario have yet to do this.

British Columbia, a Canadian standout at preventing deaths in nursing homes, adopted several wise measures early on. Way back on March 27, the western province made it illegal to work in more than one home — and topped up workers’ wages so they wouldn’t have to. It gave them full-time jobs and sick leave benefits.

It’s clear that so long as long-term care falls under provincial jurisdiction, nursing home residents will be better off in some provinces than in others. So some Canadian experts, including Stamatopoulos, are arguing that these facilities should be nationalized under the Canada Health Act. Others are not sure that’s the answer; Stall thinks it may make sense to target only for-profit homes, compelling them to improve their poor infrastructure. In the long term, any homes that do not meet modern standards should be redesigned.

Another lesson for the long term comes from Hong Kong, which has managed to totally avoid deaths in its nursing homes. Even before the coronavirus came along, all homes had a trained infection controller who put precautions in place to prevent the spread of infections. (US homes saw a similar system enacted under President Obama, but President Trump has proposed that it be rolled back.) Four times a year, Hong Kong’s homes underwent pandemic preparedness drills so that if an outbreak occurred, they’d be ready with best practices. It did, and they were.

Preparedness clearly saves lives. Hopefully, Canada and other countries will learn that lesson going forward so that no more lives are needlessly lost.

As Cahana, the resident in the Montreal home, said, “Each of us is crying to be heard. We say: More life! Please! We are not afraid of the future. We are afraid that society is forgetting us.”