Nebraska gets the nod for Medicaid work requirements

Federal judge blocks Kentucky's Medicaid work requirements

This week Nebraska became the latest state to receive waiver authority from the Trump administration to implement work requirements as part of its Medicaid expansion program.

The program, called “Heritage Health Adult”, will be a two-tiered system, with expansion-eligible adults choosing between “Basic” and “Prime” coverage levels. The lower tier will provide coverage for physical and behavioral health services, with a prescription drug benefit, and is open to adults not eligible for traditional Medicaid with incomes under 138 percent of the federal poverty line.

“Prime” enrollees will get additional dental, vision, and over-the-counter drug benefits, in exchange for agreeing to 80 hours per month of work, volunteering, or active job seeking, which must be reported to the state.

Nebraska voters approved the Medicaid expansion two years ago, although enrollment only began this August, and the work-linked demonstration project is slated to start next year. An estimated 90,000 additional Nebraskans are expected to enroll in Medicaid under the expanded program.
The approval of Nebraska’s Medicaid work requirement comes a week after the Trump administration approved a partial expansion of Medicaid in Georgia, called “Pathways to Coverage”, which is also tied to a requirement to seek or engage in employment or education activities.

The Georgia program also requires premium payments by eligible adults who make between 50 and 100 percent of the federal poverty line. Court challenges will inevitably ensue for both the Nebraska and Georgia programs—only Utah has successfully implemented Medicaid work requirements, with 16 other state programs either pending approval, held up in court, or awaiting implementation. We continue to be deeply skeptical of Medicaid work requirements, and believe they only serve to deter those who would otherwise qualify for coverage from enrolling, and that the expense of their implementation and ongoing operation often outweighs any savings to the state.

The argument that “work encourages health”, often advanced by proponents of work requirements, gets it exactly backwards—rather, health security encourages work, a reality that has become ever more urgent as the COVID pandemic has drawn on. 

As the economy continues to falter, Medicaid’s importance as a safety net program grows ever greater, and work requirements create an unhelpful obstacle to basic healthcare access.

Trump claims COVID “will go away,” Biden calls his response disqualifying

The Final Presidential Debate: The Moments That Mattered - WSJ

President Trump repeated baseless claims at the final presidential debate that the coronavirus “will go away” and that the U.S. is “rounding the turn,” while Joe Biden argued that any president that has allowed 220,000 Americans to die on his watch should not be re-elected.

Why it matters: The U.S. is now averaging about 59,000 new coronavirus infections a day, and added another 73,000 cases on Thursday, according to the Covid Tracking Project. The country recorded 1,038 deaths due to the virus Thursday, the highest since late September.

What they’re saying: “More and more people are getting better,” Trump said. We have a problem that’s a worldwide problem. This is a worldwide problem. But I’ve been congratulated by the heads of many countries on what we’ve been able to do … It will go away and as I say, we’re rounding the turn. We’re rounding the corner. It’s going away.”

  • Trump later disputed warnings by public health officials in his administration that the virus would see a resurgence in the winter, claiming: “We’re not going to have a dark winter at all. We’re opening up our country.”

Biden responded: “Anyone responsible for that many deaths should not remain as president of the United States of America.”

  • “What I would do is make sure we have everyone encouraged to wear a mask all the time. I would make sure we move in the direction of rapid testing, investing in rapid testing.”
  • “I would make sure that we set up national standards as to how to open up schools and open up businesses so they can be safe and give them the wherewithal, the financial resources, to be able to do that.”

The bottom line: Biden and Trump are living in two different pandemic realities, but Biden’s is the only one supported by health experts.

Go deeper: The pandemic is getting worse again

Are you ready for price transparency?

Exploring the Fundamentals of Medical Billing and Coding

Abstract:  This article focuses on the correct strategic response to the impending implementation of price transparency on New Year’s Day of next year.

I have stated before that I have multiple articles in process at any given time.  Some of them have been ‘in process’ for years because newer topics sometimes rise to the queue’s top.  Price transparency is an example of such a case.  I have a friend who is developing AI-enabled solutions to help organizations respond to price transparency government diktats.  Few people beyond healthcare CFOs, healthcare financial consultants, and accountants have any useful understanding of how convoluted hospital pricing has become due to decades of ill-conceived government policy for the most part.

Another problem is endless confusion over terms.  People frequently interchange the terms ‘price’, ‘cost’, ‘payment’, and ‘reimbursement’ in situations where the polar opposite is true on the other side of the issue.  In other words, ‘cost’ to a payor is price or reimbursement to a provider.

Anyway, my friend’s questions finally inspired me to go to the Federal Register, acquire the final rule, and begin the process of learning where government is headed with these regulations.  There are probably at least fifty diatribe angles I could launch into over the final rule, but I will confine my rant to only a couple of points.  

First, the final draft of the rule is ‘only’ 331 pages long. The three-column final rule in the Federal Register is ‘only’ 83 pages long.  That pales compared to Obamacare that is over 1,200 pages long, so by government standards, this is but a trifle of regulation.  

Secondly, some parts of the final rule are actually funny.  For example, CMS estimates that the average hospital will spend only 150 staff hours in the first and 46 staff hours in subsequent years complying with price transparency requirements.  Is it constitutional for government to compel private enterprises to disclose the terms of what they thought were private contracts?  Apparently so.  Once government breaks this ice, will any agreement of any type ever be private?

As I have discussed price transparency with healthcare leaders, I sense that leaders are currently focused on technical compliance with the regulations.  With COVID on their plate simultaneously, they have little capacity to take on strategic financial planning.

The final rule lays out in excruciating detail what providers face complying with the regulation.  Reading the comments and responses is equally entertaining.  CMS repeatedly says something to the effect; we heard your concern, and we’re proceeding as planned anyway.  Litigation brought by the AHA and others has to date been unsuccessful in slowing stopping the price transparency snowball that is now most of the way down the mountain.

So, what are you supposed to do?  The CFO and CIO will work, possibly with consultants’ assistance, to prepare the organization’s data release.  Soon after the release occurs, expect the defecation to hit the rotary oscillator.  The press will call out organizations with high prices, and the rancor over learning what some systems have been able to get from third-party payors will be entertaining, to say the least.  Many people believe that one of the primary motivators of the massive consolidation occurring in the healthcare industry is the market leverage exerted by growing systems on third-party payors to obtain otherwise unachievable reimbursement rates.

Regardless of the course of action following price releases in January, the intended and most likely result of this initiative is to drive prices to a lower common denominator.  A lot of people think Medicare rates will become that benchmark.  There are two significant issues that I did not see addressed in the pricing rule that will have the effect of transferring substantial risk to providers.  

The first is that there will be little if any provision for recognition of complications, comorbidities, and hospital-acquired conditions that can dramatically impact the cost of care in a given diagnosis.  

The second is the elephant in the room. The current pricing system has developed over time to facilitate cross-subsidization among payors.  There is a reason that commercial rates are so high that has nothing to do with the cost of providing care.  I have stated before that, government has turned the entire healthcare industry into a taxing authority to extract tax from commercial payors for the benefit of government payors that routinely reimburse providers below the cost of providing care.  It has been entertaining to watch the reaction of Boards of Directors when they first realize that the healthcare system has been forced by government into a wealth redistribution mechanism.

So, what happens as providers lose the ability to cross-subsidize the cost of care?  Very few hospitals (<10%) are profitable on Medicare, and it is doubtful that any hospital is breaking even on services provided to Medicaid patients.  In my experience, hospital reimbursement for self-pay patients is less than 5% of charges.  If the prices hospitals realize for services start falling and they lose the current ability to cross-subsidize the cost of care . . . . . well, you don’t need an MBA to understand the likely outcome.

What to do?  If (when) prices start falling and providers lose pricing leverage, the only place to turn is operating expense.  Hospitals that have failed to undertake serious, highly focused, and robust operating cost reduction programs that yield quantifiable results may not have a very bright future.  If your organization is not in the bottom quartile of operating cost compared to its peer group and part of your mission is to remain independent, you must be losing sleep.  In a recent article related to COVID Response, I argued that the time has come to get after clinical process variance that is the source of most of the high cost, waste, and abuse in the healthcare system. For most organizations, the days of sourcing cheaper supplies and sending nurses home early are, for the most part, over as there is little if any juice remaining in that lemon.

If, as a leader, you do not have a plan that gets you to break-even on Medicare within the next 12-18 months, you had better have a plan B, something like tuning up your CV.  I can help you with your response to price transparency, working on your CV, or helping manage your next career transition as the case may turn out.  I am as close as your phone.  Best of luck.

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Health Care in the 2020 Presidential Election: What’s at Stake

Health Care in the 2020 Presidential Election: Summary

As the presidential election draws near, we reflect on the meaningful differences in health policy priorities and platforms between the two candidates, which we’ve described more fully in our recent blog series.

While similarities exist in some areas — most notably prescription drug pricing and proposals to control health care costs — the most striking differences between the positions taken by President Donald Trump and those of former Vice President Joe Biden are on safeguarding access to affordable health care coverage, advancing health equity for those who have been historically disadvantaged by the current system, and managing the novel coronavirus pandemic.

The importance of maintaining or expanding access to affordable health care in the midst of a pandemic cannot be understated. Going into the crisis, 30 million Americans lacked health coverage, with many more potentially at risk as a result of the current economic downturn. And even for many with coverage, costs are a barrier to receiving care. Moreover, despite efforts by Congress and the Trump administration to ease the financial burden of COVID-19 testing and treatment, many people remain concerned about costs; examples of charges for COVID-related medical expenses are not uncommon.

In this context, President Trump’s efforts to repeal the Affordable Care Act (ACA) is the most important signal of his position on health care. The administration’s legal challenge of the law will be considered by the Supreme Court this fall. With no Trump proposal for a replacement to the ACA, if the Court strikes the law in its entirety or in part, many voters cannot be certain that their health coverage will be secure. By undermining the ACA — the vast law that protects Americans with preexisting health conditions and makes health coverage more affordable through a system of premium subsidies and cost-sharing assistance — the president has put coverage for millions at risk.

Trump issued an executive order to preserve preexisting condition protections. If the ACA remains intact, the order is redundant. But if the ACA is repealed by the Court, the order is meaningless because it lacks the legal underpinning and legislative framework to take effect.

In contrast, Vice President Biden has proposed expanding coverage through the ACA by adding a public option, enhancing subsidies to make health care more affordable, filling the gap for low-income families living in states that did not expand Medicaid, and giving people with employer health plans the option to enroll in marketplace coverage and take advantage of premium subsidies. For sure, if Biden is elected, many policy details must be ironed out; passing legislation in a deeply divided Congress is never easy. Despite these challenges, Biden proposes expanding health coverage rather than revoking it.

Just as COVID-19 has exposed gaps in health coverage and affordability, it also has highlighted the poor health outcomes stemming from racial and ethnic inequities in the U.S. health system. Communities of color — Black, Hispanic, and American Indian and Alaska Native people — have higher rates of COVID cases, hospitalizations, and deaths compared to white people. These disparities are a result of myriad factors, many of which are deeply rooted in structural racism. The candidates’ plans to address health disparities and advance health equity set them apart.

The ACA has played a critical role in reducing disparities in access to health care and narrowed the uninsured rate among Black and Hispanic people compared to white people. Medicaid expansion has been key to improving racial equity. Repealing the ACA, as President Trump has sought to do, would reverse these gains. Even beyond repealing the ACA, this administration has pursued policies intended to limit Medicaid eligibility — for example, by permitting states to impose work requirements and other restrictions that would lead to fewer people covered. These measures and others are already having an impact; coverage gains achieved through the ACA have eroded since 2016. Health care for legal immigrants also has declined as a result of policies like the recently finalized “public charge” rule, which seems also to have caused an increase in uninsurance among children. The administration has further revoked ACA antidiscrimination and civil rights protections for LGBTQ people.

In addition to restoring and expanding coverage under the ACA, Vice President Biden has pledged to address health disparities and reinstate antidiscrimination protections. He has a proposal to advance racial equity not just in health care but across the economy. If successful, his plan could address underlying factors contributing to higher rates of COVID-19 cases and deaths among people of color, as well as their higher rates of heart disease, diabetes, and other health conditions tied to social determinants of health.

Finally, the candidates differ deeply in their approaches to the coronavirus pandemic. President Trump has failed to orchestrate a national strategy for combating coronavirus and has routinely undermined accepted public health advice with respect to mask-wearing and social distancing. He has delegated to the states responsibility for controlling the pandemic when it is clear that the virus travels freely across the country, regardless of state borders. Lax states can negate the efforts of those states sacrificing to bring the pandemic under control. Vice President Biden has strongly signaled, though his personal conduct and rhetoric, that he intends more aggressive federal leadership in fighting the virus.

In a recent Commonwealth Fund survey of likely voters, control of the pandemic and covering preexisting conditions were very important factors in choosing a president. In seven battleground states, protections for preexisting conditions outweighed COVID-19 and health costs as the leading health care issue voters are considering. In all 10 battleground states included in the survey, Vice President Biden was viewed as the more likely candidate to address these critical health care issues.

Perhaps since the Civil War, the United States has never faced starker choices in a presidential election. In health and other areas, there are profound differences in the positions of President Trump and former Vice President Biden. Voting this November is literally a matter of life and death for the American people.

Health Care in the 2020 Presidential Election: Health Insurance Coverage and Affordability

Health Care in the 2020 Presidential Election: Coverage

The Issue

  • The number of uninsured people has increased since 2016, rising from 29 million, following the reforms of the Affordable Care Act (ACA), to 35.7 million by the end of 2019. The economic recession has left an estimated 3 million more people uninsured this year.
  • Racial inequities in coverage narrowed after the ACA, but uninsured rates among people of color exceed those of white people.
  • Many insured people pay premiums that consume an increasingly large share of their income.
  • An estimated 40 million people with insurance are effectively underinsured because of deductibles and cost-sharing.
  • An estimated 133 million people under age 65 have preexisting health conditions; COVID-19 has already increased that number by an estimated 3.4 million nonelderly adults (20–59) as of October 7.

The Candidates’ Approaches


Overall approach: Repeal the ACA and replace it with market-driven coverage options aimed at lowering premiums and increasing choice of plans tailored to individual preferences; give states more flexibility in designing coverage options; require more accountability for people with low incomes enrolled in public programs; protect preexisting conditions.

Medicaid: Repeal the ACA Medicaid expansion for adults; provide block grants to states to design their own programs; increase accountability through work requirements.

Individual market and marketplaces: Has promoted weaker regulations on plans that don’t comply with the ACA’s preexisting condition protections and other requirements; elimination of advertising and enrollment assistance during open enrollment; elimination of payments to insurers to offer lower-deductible plans.

Employer coverage: Has promoted weaker regulations on association health plans that don’t comply with the ACA and allowed employers to fund accounts for employees to buy health plans on their own, including products that don’t comply with the ACA.


Overall approach: Protect insurance for people with preexisting conditions by supporting and building on the ACA; expand insurance coverage and reduce consumers’ health care costs by enhancing the ACA’s marketplace subsidies, covering people currently eligible for Medicaid in nonexpansion states, and giving more people in employer plans the option to enroll in marketplace plans with subsidies.

Medicaid: Expand enrollment by allowing eligible people in 12 states without Medicaid expansion to enroll in a public plan through the marketplaces with no premiums; make enrollment easier with autoenrollment.

Individual market and marketplaces: Expand enrollment through enhanced subsidies, greater advertising and enrollment assistance: no one pays more than 8.5 percent of income on marketplace coverage; change the benchmark plan from silver to gold to reduce deductibles and cost-sharing.

Employer coverage: Allows anyone with employer coverage to enroll in a public plan through the marketplaces and be eligible for subsidies.

Medicare: Would allow people ages 60 to 65 to enroll in a Medicare-like heath plan.

Implications of the Candidates’ Approaches


Trump: The number of people without health insurance has increased under the president’s watch in part because of policies that have eliminated the promotion and advertising of marketplace open-enrollment periods, enrollment restrictions in Medicaid, and immigration policies that have had a chilling effect on enrollment of legal immigrants and their children. Trump supports a lawsuit now before the Supreme Court that argues for repeal of the ACA, which would eliminate coverage for as many as 20 million people. Says he will come up with a replacement but has yet to do so.

Biden: Has introduced proposals to build on the ACA by covering people in the 12 states that haven’t expanded Medicaid and enhance subsidies for marketplace plans. This would provide new options for people who are currently uninsured and increase coverage over time.


Trump: The ACA currently provides this protection. Trump supports the lawsuit before the Supreme Court that argues for repeal of the ACA and its preexisting conditions provision. Trump issued an executive order that said preexisting conditions are protected, but without the ACA or new legislation the order has no effect and is purely symbolic.

Biden: The vice president pledges to support and build on the ACA, retaining its preexisting condition protections.


Trump: The president eliminated payments to insurers to reimburse them for offering lower-deductible plans in the ACA marketplaces to people with lower incomes, as required by the law. This had the effect of increasing premiums for people not eligible for subsidies. He has promoted the sale of non-ACA-compliant health plans, like short-term plans. These plans have lower premiums for healthy people but screen for preexisting conditions and often provide little cost protection if someone becomes sick. He has loosened regulations for association health plans, although that was turned back under legal challenge. The repeal of the ACA would mean the loss of marketplace subsidies and preexisting-condition protections, making coverage unavailable or unaffordable for people with low and moderate incomes and those with health problems.

Biden: The vice president’s proposal to enhance marketplace subsidies will cap the amount of premiums people pay at 8.5 percent of income, including people in employer plans who would have the option to enroll in the marketplaces. By linking subsidies to gold plans, deductibles would also fall for those who choose those plans.


Trump: Uninsured rates among Hispanic people have risen under the president’s watch. Repealing the ACA would further eliminate coverage gains made by Hispanics, as well as Black people and Asian Americans, widening racial disparities in coverage and access.

Biden: The vice president’s proposals to expand coverage under the ACA will particularly benefit people of color. This is because people living in the 12 states that have not yet expanded Medicaid are disproportionately Black and Hispanic.

Health Care in the 2020 Presidential Election — A Commonwealth Fund Blog Series

Comparing the Candidates' Health Care Plans

Before each presidential election, the Commonwealth Fund analyzes the major health policy positions of the Democratic and Republican candidates to assist Americans in making informed choices. In 2020, with health care rising to the top of the electorate’s concerns for myriad reasons, this information has never been more important.

In the next week, we will be publishing a series of analyses that compare the positions of President Donald Trump and his challenger, former Vice President Joe Biden, on topics like:

prescription drug policy;

the affordability and availability of health care and insurance, including the issue of preexisting conditions;

questions concerning older adults, like Medicare; how best to control the costs of health care;

addressing mental and behavioral health concerns;

and strategies for advancing health care equity.

In most previous presidential election years, we have had the opportunity to compare fairly well-delineated party and candidate programs. In 2020, President Trump and the Republican party have chosen not to issue any party platform or formal policy positions. Therefore, we have derived our description of President Trump’s program from the policies he espoused, and decisions made during his first term. Vice President Biden’s information comes from his campaign platform.

We hope you find these summaries helpful as you weigh your choices for Election Day.

Hospitals that don’t submit daily COVID-19 data could lose participation in Medicare, Medicaid

US Department of Health and Human Services moves to Microsoft Office 365

Hospitals currently not reporting daily COVID-19 data have a few months to get in compliance or risk being thrown out of Medicare and Medicaid.

The Department of Health and Human Services (HHS) announced Tuesday it will send notices to all hospitals over their requirements for reporting COVID-19 data to the Trump administration.

Any hospital not in compliance with the daily reporting requirements will have 14 weeks to get in line or risk their participation in Medicare and Medicaid, officials said.

The agency gave an enforcement timeline that gives “hospitals ample opportunity to come into compliance,” said Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma on a call with reporters Tuesday.

The Trump administration wants hospitals to submit daily data that includes COVID-19 deaths and hospitalizations as well as patients currently in the intensive care unit with the virus. Hospitals must submit data on the ages of patients admitted with suspected COVID-19 infections. Facilities need to also report their inventory of the COVID-19 therapy Remdesivir, any staffing shortages and the number of ventilators. Every week hospitals also report data on their personal protective equipment on hand and supply of critical medications.

Facilities now must also report on new data for influenza cases. “The new requirements will allow us to gather critical information on influenza at hospitals across the U.S.,” said Centers for Disease Controls and Prevention Director Robert Redfield, M.D.

Verma said that the large majority of hospitals in CMS’ system are already reporting this data to the agency. CMS will also give hospitals that are not in compliance a wide berth to get them into compliance.

Hospitals will be sent multiple notices over the 14-week timeline to get their data reporting in line.

“This work of getting hospitals into compliance around reporting has been an ongoing effort,” Verma said.

CMS proposed the mandatory daily reporting requirements back in August, much to the chagrin of hospital advocates. 

The American Hospital Association (AHA) said that CMS tying Medicare and Medicaid participation to compliance “remains an overly heavy-handed approach that could jeopardize access to hospital care for all Americans,” according to a statement released Tuesday. 

“Today’s interpretive guidance on COVID data reporting does answer some of the questions hospitals and health systems have been asking about compliance since the interim final rule was released six weeks ago,” the group said. “In particular, the Administration will provide hospitals with information on whether their data are making it into HHS Protect and they will give hospitals the necessary time to adjust their data collection to come into compliance if need be.”

The Federation of American Hospitals called the new rules “sledgehammer enforcement.”

“It is both inappropriate and frankly overkill for CMS to tie compliance with reporting to Medicare conditions of participation,” said FAH President and CEO Chip Kahn in a statement.

States ranked by uninsured rates

Uninsured Rate by State: Percentage of People Without Health Insurance

Texas has the highest uninsured rate in the U.S., and Massachusetts has the lowest, according to an analysis by WalletHub, a personal finance website. 

To measure the rates of uninsured by state, analysts compared the overall insurance rates of each state in 2019 using U.S. Census Bureau data. Analysts also examined the state rates based on age, race and income. Access more information about the methodology here.

Massachusetts has the lowest uninsured rate for adults and children, at 3.39 percent and 1.52 percent, respectively. In Texas, which ranked last, the children’s uninsured rate is 12.75 percent and the adults’ uninsured rate is 20.47 percent. 

Here is each state ranked from lowest to highest uninsured rate, according to the analysis: 

1. Massachusetts

2. Rhode Island

3. Hawaii

4. Vermont

5. Minnesota

6. Iowa

7. New York

8. Wisconsin

9. Pennsylvania

10. Michigan

11. Connecticut

12. Maryland

13. New Hampshire

14. Kentucky

15. Delaware

16. Ohio

17. Washington

18. West Virginia

19. North Dakota

20. Oregon

21. Illinois

22. California

23. New Jersey

24. Virginia

25. Colorado

26. Maine

27. Montana

28. Nebraska

29. Indiana

30. Louisiana

31. Arkansas

32. Kansas

33. Utah

34. Alabama

35. New Mexico

36. Missouri

37. Tennessee

38. South Dakota

39. Idaho

40. South Carolina

41. North Carolina

42. Arizona

43. Nevada

44. Alaska

45. Wyoming

46. Mississippi

47. Florida

48. Georgia

49. Oklahoma

50. Texas

State autonomy versus a fundamental right: VP debate will spotlight divergent healthcare views

Mike Pence and Kamala Harris take the debate stage Wednesday night. (Kamala (Harris photo by Ethan Miller; Pence photo by Joshua Roberts. Both Getty Images)

The undercurrent of the VP debate is the age and health of the two men vying for the presidency.

The two remaining presidential debates, scheduled for October 15 and 22, are in question due to President Trump’s positive COVID-19 and quarantine status, making the vice presidential debate this Wednesday at 9 p.m. even more important than VP debates of past elections.

The undercurrent in the debate consists of the ages of challenger Biden, who is 77 and turning 78 before the end of the year, and Trump, 74, who has been hospitalized for COVID-19 and was released from Walter Reed Army Medical Center on Monday afternoon. Trump has said he plans to debate Biden on October 15.

This VP debate is big, said Paul Keckley, a healthcare policy analyst and managing editor of the Keckley Report. 

“The reason is not so much the two are debating,” Keckley said. “We have a 77- year-old challenger and a 74-year-old incumbent. Voters are expecting the odds are one will become disabled and the vice president is going to step in. That’s the undercurrent of this debate.”

Healthcare is an obvious dominant theme Wednesday night beyond the health of the two men seeking the presidency. 

It is expected that Biden’s running mate, Kamala Harris will challenge Vice President Mike Pence on his role heading the coronavirus task force when close to 7.5 million people in this country have been infected with COVID-19 and more than 200,000 have died.

Pence will likely challenge Harris on her support for Medicare for All before she backtracked to support Biden’s public-private option for healthcare coverage.

Pence and Harris are expected to lay out the healthcare plans of their respective Republican and Democratic nominees less than four weeks before the election, in a way the lead candidates failed to get across during the first presidential debate that presented more chaos than clarity.


Trump and Biden differ fundamentally on whether the federal government should be involved in the business of providing healthcare coverage.

Trump’s guiding principles rest on the pillar of state autonomy as opposed to a federalized healthcare system and Biden’s maxim that healthcare is a right, not a privilege. 

Trump believes that private solutions are better than government solutions, according to Keckley. He is much less restrained on private equity and the Federal Trade Commission’s scrutiny of vertical integration. States become the gateway to the market as private solutions are sold to states as innovation.

Trump’s other concept is that the door to engaging consumers in healthcare is price transparency. His view is that price transparency will spawn consumer engagement.

Centers for Medicare and Medicaid Services Administrator Seema Verma, who was appointed by Trump in 2016 based largely on the recommendation of Pence, is instituting a rule, starting January 1, 2021, requiring hospitals to have price transparency for 300 shoppable services. Hospitals are being required to make their contract terms with payer accessible.

This is separate from CMS’s interoperability rule aimed at payers that also goes into effect on January 1.

Trump believes healthcare is a personal responsibility, not a public obligation. To Trump, healthcare is a marketplace where there are winners and losers, according to Keckley.

Biden has a more developed policy platform on making healthcare a universal right, starting with strengthening the Affordable Care Act that was passed while Biden was vice president during President Barack Obama’s terms.

Biden wants to increase the eligibility for tax subsidies in the ACA up to 400% of the federal poverty level, which would expand access to subsidized health insurance.

He also wants to reduce the affordability threshold for employer insurance. Currently, if employees pay more than 9.7% of their adjusted income for their workplace coverage, they can seek a plan in the ACA marketplace. Biden would lower that eligibility for ACA coverage to 8.5%, opening the door for many more consumers to be insured through the ACA, at a lower cost.

Biden would also lower the age of eligibility for Medicare from 65 to 60.

For companies such as manufacturing and transportation, in which individuals can retire after 30 years of service, this lets them into the Medicare system earlier to fill that gap between retirement and Medicare eligibility.

Biden’s public option would create insurance plans that would compete with private plans. 

The other factor to watch on the Biden side, Keckley said, is his clear focus on equity and diversity in healthcare. 


Biden wants to strengthen Obamacare while Trump is actively pursuing a repeal of the law through the Supreme Court. 

President Trump’s debate prep and the White House Rose Garden event announcing the nomination of Judge Amy Coney Barrett to replace the late Supreme Court Justice Ruth Bader Ginsburg, border on the definition of super spreader events.

The Justices, perhaps with the addition of Trump’s pick, Amy Coney Barrett, if there are enough Republican senators well enough and in attendance to vote for confirmation, are scheduled to hear oral arguments in the case brought by 18 GOP-led states on November 10, the week after the election.

Senators must be present to vote, and Republicans, who have a majority of 53 to 47 seats, need a four-vote majority. Two Republican senators – Susan Collins of Maine and Lisa Murkowski of Alaska – have said they wouldn’t vote on a nominee prior to the election. Vice President Mike Pence could cast the deciding vote in a tie.

Three Republican senators have tested positive for the coronavirus. Sens. Mike Lee of Utah and Thom Tillis of North Carolina, who sit on the Judiciary Committee, tested positive for COVID-19 days after attending the White House Rose Garden event on September 26. Republican Sen. Ron Johnson of Wisconsin is now the third to test positive, though he did not attend that event.

There was a lack of social distancing and mask wearing at both the Rose Garden nomination and at a meeting between Trump and staff for debate prep. Twelve people in Trump’s inner circle, including his wife Melania, former New Jersey governor Chris Christie and White House Press Secretary Kayleigh McEnany, have tested positive since attending.

Senate Majority Leader Mitch McConnell wrote in an email to GOP senators obtained by CNN that he needs all Republican senators back in Washington by October 19.


Trump announced in a tweet Monday that he would be leaving Walter Reed later in the afternoon, saying he felt “really good!” and adding, “Don’t be afraid of Covid. Don’t let it dominate your life. We have developed, under the Trump Administration, some really great drugs & knowledge. I feel better than I did 20 years ago!”

Trump has been criticized for leaving the hospital on Monday to take a drive-by ride to wave to supporters. Attending physician Dr. James Phillips called the action “insanity” and “political theater” that put the lives of Secret Service agents in the car with him at risk.

Trump has downplayed the virus in an effort to reopen the country and the economy, and has put the blame on China, where the coronavirus originated.

Trump told Biden during the debate, “We got the gowns; we got the masks; we made the ventilators. You wouldn’t have made ventilators – and now we’re weeks away from a vaccine.” 

Biden puts the blame squarely on Trump for delaying action to stop the spread.

Biden said during the debate: “Look, 200,000 dead. You said over seven million infected in the United States. We in fact have 5% or 4% of the world’s population – 20% of the deaths. Forty thousand people a day are contracting COVID. In addition to that, about between 750 and 1,000 people, they’re dying. When [Trump] was presented with that number he said ‘It is what it is’ – what it is what it is – because you are who you are. That’s why it is. The president has no plan. He hasn’t laid out anything.”

Biden said that back in July he laid out a plan for providing protective gear and providing money the House passed to get people the help they need to keep their businesses open and open schools. 

Under Trump’s Administration, Congress passed $175 billion in provider relief funds for hospitals, small businesses, individuals and others – $100 billion from the CARES Act and $75 billion from the Paycheck Protection Program and Healthcare Enhancement Act.


CMS Administrator Seema Verma was healthcare advisor to Pence while he was governor of Indiana. Her consulting firm, SVC, Inc., worked closely with Pence to design Indiana’s Medicaid expansion under the Affordable Care Act. They developed a unique Medicaid expansion program called Health Indiana Plan 2.0, which mandated low income adults above the poverty level pay monthly premiums for their healthcare. 

Members who did not pay faced being disenrolled for six months. 

As administrator, Verma has initiated similar work requirements for Medicaid coverage nationwide.

While as governor Pence implemented Medicaid expansion, as vice president he has supported torpedoing the ACA, and has pushed the Graham-Cassidy plan for healthcare reform that would have replaced the ACA.


Neither Trump nor Biden has taken on the pharmaceutical industry in a meaningful way, though both have voiced a strong belief that drug manufacturers are egregious to the system, according to Keckley.

“Both camps are saying, we’re really going to take them on,” he said. 

During the debate, Trump said he was cutting drug prices by allowing American consumers to buy drugs from Canada and other countries under a favored nation status. 

“Drug prices will be coming down, 80 or 90 percent,” Trump said during the debate, telling Biden he hadn’t done anything similar during his 47 years in government.

If Trump gets a second term, there will likely be more industry folks in his circle, following up on his first term of stacking his cabinet with business people.

Biden would be more likely to lean toward a blend of public health officials and industry executives. There would be more of a spotlight on wealth creation in healthcare and executive pay.

In the $1.1 trillion world of prescription drugs, the United States makes up 40% of the market. 

“We’re the hub of the prescription drug industry,” Keckley said. 

New Laws Strengthen California’s Response to Mental Health Crises

Governor Newsom signs legislation expanding access to quality behavioral health care.

Governor Newsom signs into law four bills expanding access to quality behavioral health care at a ceremony in Sacramento on September 25, 2020. Photo: Paula Ginsborg via YouTube

Governor Gavin Newsom has signed into law four bills intended to improve Californians’ access to mental health and substance use disorder services.

I pledged to put these critical services within reach of more Californians,” Newsom said in a September 25 statement. “The bills I am signing today will help Californians access the behavioral health services they need to recover.”

Essential Coverage

The coronavirus pandemic and the resulting economic downturn have persuaded Americans of the importance of behavioral health care services. In the last half of August, a National Council for Behavioral Health poll (PDF) found that the gap has widened considerably between demand for mental health and addiction treatment services and the financial viability of organizations that provide them. Over half of NCBH member organizations reported that in the three months before the survey, more Americans sought their services even as these providers lost, on average, 23% of their annual revenue.

A different survey, conducted in the last week of June, showed that one in four people age 18 to 24 seriously considered suicide in the past 30 days. That troubling finding was published in the Morbidity and Mortality Weekly Report of the US Centers for Disease Control and Prevention.

In California, where the wildfire season got off to an early and destructive start, the converging crises are expected to worsen residents’ mental health. “We are very concerned about the layering of multiple stresses on the people of California,” Jim Kooler, DrPH, assistant deputy director of behavioral health in the California Department of Health Care Services, told Jocelyn Wiener in CalMatters.

Newsom, who signaled his commitment to mental health during his campaign for governor, became visibly emotional at the end of the September 25 virtual bill-signing ceremony. “Thanks for leading, thanks for making a difference,” he said to the legislators and mental health advocates on the video call. “This is making a difference in real people’s lives.”

Here are the four behavioral health bills that the governor approved:

Strengthening California’s Mental Health Parity Law

Gaps in California’s mental health parity law will be bridged under SB 855 by State Senator Scott Wiener (D-San Francisco). “Current state law requires health plans to cover medically necessary treatment of just nine serious mental illnesses,” Jocelyn Wiener reported in an article about SB 855.

Mental health parity laws “have existed in both state and federal law for years, but insurers have used a complex determination of ‘medical necessity’ to deny care” for mental health issues and substance use disorders, Sigrid Bathen wrote in Capitol Weekly. (A recently published CHCF paper by researchers at Georgetown University’s Center on Health Insurance Reforms assessed California’s progress in enforcing the 2008 federal Mental Health Parity and Addiction Equity Act.)

The new state law requires commercial health plans and insurers outside of Medi-Cal (which is regulated by different standards) to provide full coverage for treatment of all mental health conditions and substance use disorders. This includes treatments for post-traumatic stress disorder, generalized anxiety disorder, and opioid use disorder, Sophia Bollag wrote in the Sacramento Bee. The new law also establishes specific standards for what constitutes medically necessary treatment and criteria for the use of clinical guidelines.

Creating a Certification Process for Peer Support Specialists

Under SB 803 by State Senator Jim Beall (D-San Jose), California will create a system to certify peer support specialists, define their roles, and help to scale up the Medi-Cal workforce.

In 2019, CHCF’s Lisa Aliferis visited Washington State to learn about its innovative statewide peer support program. A certified peer support specialist “identifies as having a significant life-altering mental health [or substance use] challenge and has been in recovery for at least a year,” Aliferis was told by Patti Marshall, the peer support program administrator for the Washington Health Care Authority’s behavioral health and recovery division.

Last year, California had not adopted a similar program — even though the US Centers for Medicare & Medicaid Services issued Medicaid reimbursement guidelines for peer providers in 2007. Now, research has shown that peer support for those with co-occurring mental health and substance use diagnoses prevents rehospitalizations and facilitates their ability to live in the community. “When we say [peer support] saves lives, it’s not hyperbole,” Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California, told Jocelyn Wiener in an article about peer support specialists. “It really is a linchpin in moving people [with mental health and substance use disorder issues] into recovery and stabilizing them long-term.”

Expanding Community Paramedicine

Community paramedicine is a locally designed, community-based, collaborative model of care that leverages the skills of paramedics and emergency medical services (EMS) systems to take advantage of collaborations between EMS and other health care and social service providers. Among other expanded roles, community paramedics are trained to handle behavioral health needs and, depending on the locally designed program, can transport intoxicated patients to sobering centers or mental health treatment, and help frequent 911 callers to obtain behavioral health, medical, housing, and social services. All of these protocols take pressure off hospital emergency departments that traditionally have been the only permitted destinations for patients cared for by EMS agencies.

In 2015, California began testing the model of care through 13 community paramedicine pilot projects across the state. An external evaluation conducted by the Healthforce Center at UCSF found that “community paramedics are collaborating successfully with physicians, nurses, behavioral health professionals, social workers, and outreach workers to fill gaps in the health and social services safety net.”

AB 1544 by Assemblymember Mike Gipson (D-Carson) will expand the pilot projects by authorizing local EMS agencies to develop alternative destination programs.

Learn how community paramedics in San Francisco and San Diego have been deployed by their local jurisdictions to help people experiencing homelessness during the pandemic.

Making Substance Use Disorder Treatment More Accessible

One-third of adults who receive county services for serious mental illnesses have a co-occurring substance or alcohol use disorder, according to Assemblymember Sharon Quirk-Silva (D-Fullerton). She authored AB 2265, which will authorize counties to use Mental Health Services Act (MHSA) funds — historically limited to mental health services — to treat Californians with co-occurring mental health and substance use disorders.

By removing barriers to using MHSA-funded services for such conditions, AB 2265 will “[increase] access to substance use disorder treatment, [improve] care coordination, and [lead] to a more integrated behavioral health care system,” according to the governor’s office.