The Battle Over State Bailouts

https://www.politico.com/news/magazine/2020/06/01/coronavirus-state-bailout-budget-jobs-economy-impact-287704

Blue State Bailout? Red State Residents Received Largest Stimulus ...

Why Politics Keeps Tanking a Bailout Idea That Works.

Nobody in Congress likes to give other politicians money. But the track record shows that writing checks directly to states could keep the recession from becoming way worse.

The last time the American economy tanked and Washington debated how to revive it, White House economists pushed one option that had never been tried in a big way: Send truckloads of federal dollars to the states.

When President Barack Obama took office in January 2009 during the throes of the Great Recession, tax revenues were collapsing and state budgets were hemorrhaging. The Obama team was terrified that without a massive infusion of cash from Congress, governors would tip the recession into a full-blown depression by laying off employees and cutting needed services. So the president proposed an unprecedented $200 billion in direct aid to states, a desperate effort to stop the bleeding that amounted to one-fourth of his entire stimulus request.

But the politics were dismal. Republican leaders had already decided to oppose any Obama stimulus. And even Washington Democrats who supported their new leader’s stimulus weren’t excited to help Republican governors balance their budgets. Most politicians enjoy spending money more than they enjoy giving money to other politicians to spend. And since state fiscal relief was a relatively new concept, the Obama team’s belief that it would provide powerful economic stimulus was more hunch-based than evidence-based.

Ultimately, the Democratic Congress approved $140 billion in state aid—only two-thirds of Obama’s original ask, but far more than any previous stimulus.

And it worked. At least a dozen post-recession studies found state fiscal aid gave a significant boost to the economy—and that more state aid would have produced a stronger recovery. The Obama team’s hunch that helping states would help the nation turned out to be correct.

But evidence isn’t everything in Washington. Now that Congress is once again debating stimulus for a crushed economy—and governors are once again confronted with gigantic budget shortfalls—a partisan war is breaking out over state aid. Memories of 2009 have faded, and the politics have scrambled under a Republican presidential administration.

Democratic leaders have made state aid a top priority now that Donald Trump is in the White House, securing $150 billion for state, local and tribal governments in the CARES Act that Congress passed in March, and proposing an astonishing $915 billion in the HEROES Act that the House passed in May. Republican leaders accepted the fiscal relief in the March bill, but they kept it out of the last round of stimulus that Congress enacted in April, and they have declared the HEROES Act dead on arrival. Though they’re no longer denouncing stimulus as socialism, as they did in the Obama era, they’ve begun attacking state aid as a “blue-state bailout.”

Polls show that most voters want Washington to help states avoid layoffs of teachers, police officers and public health workers, but Senate Majority Leader Mitch McConnell, Fox News personalities, and other influential Republicans are trying to reframe state aid as Big Government Democratic welfare spending. Trump doesn’t want to run for reelection during a depression, and he initially suggested he supported state aid, but in recent weeks he has complained that it would just reward Democratic mismanagement.

“There wasn’t a lot of evidence that state aid would be good stimulus in 2009, but now there’s a lot of data, and it all adds up to juice for the economy,” Moody’s chief economist Mark Zandi says. “It’s baffling that this is getting caught up in politics. If states don’t get the support they need soon, they’ll eliminate millions of jobs and cut spending at the worst possible time.”

The coronavirus is ravaging state budgets even faster than the Great Recession did, drying up revenue from sales taxes and income taxes while ratcheting up demand for health and unemployment benefits. But as Utah Republican Senator Mitt Romney pointed out earlier this month: “Blue states aren’t the only ones who are getting screwed.” Yes, California faces a $54 billion budget shortfall, and virus-ravaged blue states like New York and New Jersey are also confronting tides of red ink. But the Republican governors of Texas, Georgia and Ohio have also directed state agencies to prepare draconian spending cuts to close massive budget gaps.

Fiscal experts say the new Republican talking point that irresponsible states brought these problems on themselves with unbalanced budgets and out-of-control spending has little basis in reality. Unlike the federal government, which was running a trillion-dollar deficit even before the pandemic, every state except Vermont is required by law to balance its budget every year. State finances were unusually healthy before the crisis hit; overall, they had reserved 7.6 percent of their budgets in rainy day funds, up from 5 percent before the Great Recession.

But now, governors of both parties are now pivoting to austerity, which means more public employees applying for unemployment benefits, fewer state and local services in a time of need, and fewer dollars circulating in the economy as it begins to reopen.

Federal Reserve Chairman Jerome Powell, who has approved a plan to buy up to $500 billion worth of state and local government bonds to help ease their money problems, recently suggested that direct federal aid to states also “deserves a careful look,” which in Fed-speak qualifies as a desperate plea for congressional action.

Nevertheless, some Republicans who traditionally pushed to devolve power from the federal government to the states are now dismissing state aid as a bloated reward for liberal profligacy. Some fiscal conservatives have merely suggested that the nearly trillion-dollar pass-through to states, cities and tribes in the House HEROES bill is too generous given the uncertainties about the downturn’s trajectory. McConnell actually proposed that states in need should just declare bankruptcy, which is not even a legal option. Former Wisconsin Governor Scott Walker wrote a New York Times op-ed titled “Don’t Bail Out the States.” Sean Hannity told his Fox viewers that more fiscal relief would be a tax on “responsible residents of red states,” while Florida Senator (and former Governor) Rick Scott said it would “bail out liberal politicians in states like New York for their unwillingness to make tough and responsible choices.”

It was not so long ago that governors like Walker and Scott were burnishing their own reputations for fiscal responsibility with federal stimulus dollars. Obama’s American Recovery and Reinvestment Act was a bold experiment in using federal dollars to backstop states in an economic emergency, and its legacy hangs over the debate over today’s emergency.

By the time Obama won the 2008 election, the U.S. economy had already begun to collapse, and his aides had already given him a stimulus memo proposing a $25 billion “state growth fund.” The goal was anti-anti-stimulus: They wanted to prevent state spending cuts and tax hikes that would undo all the stimulus benefits of federal spending increases and tax cuts. The memo warned that states faced at least $100 billion in budget shortfalls, and that “state spending cuts will add to fiscal drag.” Cash-strapped states would also cut funding to local governments, accelerating the doom loop of public-sector layoffs and service reductions, pulling money out of the economy when government ought to be pouring money in.

The memo also warned that the fund might be caricatured as a bailout for irresponsible states and might run counter to the self-interest of politicians who enjoy dispensing largesse: “Congress may resist spending money that governors get credit for spending.” House Speaker Nancy Pelosi of California wasn’t keen on creating a slush fund for her state’s Republican governor, Arnold Schwarzenegger, and House Majority Whip James Clyburn of South Carolina was even more suspicious of his GOP governor, Mark Sanford, an outspoken opponent of all stimulus and most aid to the poor.

After President-elect Obama addressed a National Governors Association event in Philadelphia, Sanford and other conservative Republicans publicly declared that they didn’t want his handouts—and many congressional Democrats were inclined to grant their wish. Even Obama’s chief of staff, Rahm Emanuel, was worried about the politics of writing checks to governors who might run against Obama in 2012 on fiscal responsibility platforms.

There were plenty of studies suggesting that unemployment benefits and other aid to recession victims was good economic stimulus, because families in need tend to spend money once they get it, but there wasn’t much available research about aid to states. Congress had approved $20 billion in additional Medicaid payments to states in a 2003 stimulus package, but that aid had arrived much too late to make a measurable difference in the much milder 2001 recession.

Still, Obama’s economists speculated that state aid would have “reasonably large macroeconomic bang for the buck.” And the holes in state budgets were expanding at a scary pace, doubling in the first week after Obama’s election, increasing more than fivefold by Inauguration Day; Robert Greenstein of the Center on Budget and Policy Priorities remembers giving the Obama team frequent updates on state budget outlooks that seemed to deteriorate by the hour.

Obama ended up requesting $200 billion in state fiscal relief in the Recovery Act, eight times his team’s suggestion from November, 10 times more than Congress had authorized in 2003. Emanuel insisted on structuring the aid through increases in existing federal support for schools and Medicaid, rather than just sending states money, so it could be framed as saving the jobs of teachers and nurses. (One otherwise prescient memo by Obama economic aide Jason Furman suggested the unwieldy title of “Tax Increase and Teacher & Cop Layoff Prevention Fund.”) Republicans overwhelmingly opposed the entire stimulus, so Democrats dictated the contents, and they grudgingly agreed to most of their new president’s request for state bailouts.

“State aid was the part of the stimulus where Obama met the most resistance from Democrats,” Greenstein says. “It had such a huge price tag, and nobody loved it. But we can see how desperately it was needed.”

The Obama White House initially estimated that each dollar sent to states would generate $1.10 in economic activity, compared with $1.50 for aid to vulnerable families or infrastructure projects that had been considered the gold standard for emergency stimulus. But later work by Berkeley economist Gabriel Chodorow-Reich and others concluded the actual multiplier effect of the Medicaid assistance in the Recovery Act was as high as $2.00. In addition to preventing cuts in medical care for the poor, it saved or created about one job for every $25,000 of federal spending—and the help arrived much faster than even the most “shovel-ready” infrastructure projects, landing in state capitals just a week after the stimulus passed.

“There were at least a dozen papers written on the state aid, and the evidence is crystal clear that it helped,” says Furman, who is now an economics professor at Harvard. “Unfortunately, it was incredibly hard to get Congress to do more of it, and that hurt.”

After all the bluster about turning down Obama’s money, the only Republican governor who even tried to reject a large chunk of the federal stimulus was Sanford, who was overruled by his fellow Republicans in the South Carolina Legislature. Sarah Palin of Alaska did turn down some energy dollars, while Walker and Scott sent back aid for high-speed rail projects approved by their Democratic predecessors, but otherwise the governors all used the cash to help close their budget gaps. Bobby Jindal of Louisiana appeared at the ribbon-cutting for one Recovery Act project wielding a giant check with his own name on it. Rick Perry of Texas used stimulus dollars to renovate his governor’s mansion—which, in fairness, had been firebombed.

Nevertheless, the Recovery Act covered only about 25 percent of the state budget shortfalls, and Republican senators blocked or shrank Obama’s repeated efforts to send more money to states, forcing governors of both parties to impose austerity programs that slashed about 750,000 state and local government jobs. In 2010, 24 states laid off public employees, 35 cut funding for K-12 education, 37 cut prison spending, and 37 cut money for higher education, one reason for the sharp increases in student loan debt since then. In a recent academic review of fiscal stimulus during the Great Recession, Furman estimated that if state and local governments had merely followed their pattern in previous recessions, spending more to counteract the slowdown in the private sector, GDP growth would have been 0.5 percent higher every year from 2009 through 2013.

The Recovery Act helped turn GDP from negative to positive within four months of its passage, launching the longest period of uninterrupted job growth in U.S. history. But there’s a broad consensus among economists that austerity in the form of layoffs and reduced services at the state and local level worked against the stimulus spending at the federal level, weakening the recovery and making life harder for millions of families.

“The states would’ve made much bigger cuts without the Recovery Act, but they did make big cuts,” says Brian Sigritz, director of fiscal studies at the National Association of State Budget Officers. “We’re seeing similar reactions now, except the situation is even worse.”

It took a decade for state budgets to recover completely from the financial crisis. 2019 was the first year since the Great Recession that they grew faster than their historic average, and the first year in recent memory that no state had to make midyear cuts to get into balance. Rainy-day funds reached an all-time high.

And then the pandemic arrived.

The government sector shed nearly a million jobs in April alone, which is more jobs than it lost during the entire Great Recession. The fiscal carnage has not been limited to states like New York and New Jersey at the epicenter of the pandemic; oil-dependent states like Texas and tourism-dependent states like Florida have also seen revenues plummet. The bipartisan National Governors Association has asked Congress for $500 billion in state stabilization funds, warning that otherwise governors will be forced to make “drastic cuts to the programs we depend on to provide economic security, educational opportunities and public safety.”

So far, Congress has passed four coronavirus bills providing about $3.6 trillion in relief, including $200 billion in direct aid to state, local and tribal governments for Medicaid and other pandemic-related costs. Republican Governor Charlie Baker of Massachusetts says the aid has come in handy in fighting the virus—not only for providing health care and buying masks but for helping communities install plexiglass in consumer-facing offices and pay overtime to essential workers. Massachusetts had more than 10 percent of its expected tax revenues in its rainy-day fund before the crisis, but its revenues have dried up, putting tremendous pressure on the state as well as its 351 local governments.

“You don’t want states and locals to constrict when the rest of the economy is trying to take off,” Baker said. “So far, we’ve gotten close to what we need, but the question is what happens now, because no one knows what the world is going to look like in a few months.”

In the initial coronavirus bills, Democrats pushed for state aid, and Republicans relented. But in the most recent stimulus that Congress enacted, the $733 billion April package focused on small-business lending, Democrats pushed for state aid and Republicans refused. McConnell has said he’s open to another stimulus package, but he has ridiculed the $3 trillion Democratic HEROES Act as wildly excessive, and rejected its huge proposal for state relief as a bailout for irresponsible blue states with troubled pension funds. Sean Hannity expanded the critique, warning Fox viewers that they were being set up to help Democratic states pay off their “unfunded pensions, sanctuary state policies, massive entitlements, reckless spending on Green New Deal nonsense, and hundreds of millions of dollars of waste.”

In fact, the state with the most underfunded pension plan is McConnell’s Kentucky, which has just a third of the assets it needs to cover its obligations, even though it had unified Republican rule until a Democrat rode the pension crisis to the governor’s office last fall. In general, red states tend to be more dependent on federal largesse than blue states, which tend to pay more taxes to the federal government; an analysis by WalletHub found that 13 of the 15 most dependent states voted for Trump in 2016, with Kentucky ranking third.

Trump initially suggested state aid was “certainly the next thing we’re going to be discussing,” before embracing McConnell’s message that state bailouts would unfairly reward incompetent Democrats in states like California. But California’s finances were also in solid shape before the pandemic, with a $5 billion surplus announced earlier this year in addition to a record $17 billion socked away in its rainy-day fund. Some of the partisan arguments against state aid have been flagrantly hostile to economic evidence; Walker’s op-ed actually blamed the state budget shortfalls after the Great Recession on “the disappearance of federal stimulus funds,” rather than the recession itself, as if the stimulus funds somehow created the holes by failing to continue to plug them.

But plenty of Republican politicians support state aid, especially in states that need it the most. The GOP chairmen of Georgia’s appropriations committees recently asked their congressional delegation to support relief “to close the unprecedented gap in dollars required to maintain a conservative and lean government framework of services.” Some Republicans believe McConnell’s opposition to state fiscal relief is just a negotiating ploy, so he can claim he’s making a concession when it gets included in the next stimulus bill.

“Some aid to states is inevitable and necessary,” says Republican lobbyist Ed Rogers. “I suspect McConnell just wants to set a marker, and make sure aid to states doesn’t become aid to pension funds and public employee union coffers.”

That said, it’s not just Republican partisans who are skeptical of the Democratic push for nearly a trillion dollars in state and local aid. The current projections of state budget gaps range as high as $650 billion over the next two years, but some deficit hawks question whether it’s necessary to fill all of them before it’s clear how long the economic pain will last, and before the Fed has even begun its government bond-buying program. Maya MacGuineas, president of the Center for a Responsible Federal Budget, was already disgusted by the trillion-dollar deficits that Washington ran up before the pandemic, and while she says it makes sense to add to those deficits to prevent states from making the crisis worse with radical budget cuts, she doesn’t think federal taxpayers need to cater to every state-level request.

“We have a little time to catch our breath now, so we should make sure that we’re only getting states what they need,” MacGuineas says. “It’s not a moment to be padding the asks.”

Tom Lee, a Republican state senator and former Senate president, says it’s impossible to know how much help states will need without knowing how quickly the economy will reopen, whether there will be a second wave of infections, when Americans will return to their old travel habits, and at what point there will be treatment or a vaccine for the virus. More than three-quarters of Florida’s general revenue comes from sales taxes, so a lot depends on when Floridians start buying things again, and how much they’re willing to buy. Lee says it’s reasonable to expect Washington to help in an emergency, since the national government can print money and Florida can’t, but that the federal money store can’t be open indefinitely, since Florida’s finances were in much better shape than Washington’s before the emergency.

“No question, we need help, but we can’t expect the feds to make us whole,” Lee says. “We’re going to have to tighten our belts, too.”

That’s exactly what Keynesian economic stimulus is supposed to avoid: the contraction of public-sector spending at a time when private-sector spending has already shriveled. A recent poll by the liberal group Data for Progress found that 78 percent of Americans supported $1 trillion in federal aid to states so they can “avoid making deep cuts to government programs and services.”

But Obama White House veterans say they learned two related lessons from their experience with state fiscal relief: It’s better to get too much than not enough, and it’s unwise to assume you can get more later. Stimulus fatigue was real in 2009, and it seems to be returning to Washington. Republicans who spent much of the Obama era screaming about the federal deficit have embraced a free-spending culture of red ink under Trump, but lately they’re starting to talk more about slowing down—not only with state aid, but especially with state aid.

“We’ve already seen how state contraction can undo federal expansion,” Furman says. “This is the one part of the economy where we know exactly what needs to be done, and we don’t need to invent a brand new creative idea. But I worry that we’re not going to do it.”

 

 

 

COVID-19, Unemployment Compensation, and State Medicaid Expansion Decisions

https://www.rwjf.org/en/library/research/2020/05/covid-19-unemployment-compensation-and-state-medicaid-expansion-decisions.html?utm_source=The+Fiscal+Times&utm_campaign=04962bd706-EMAIL_CAMPAIGN_2020_05_29_09_07&utm_medium=email&utm_term=0_714147a9cf-04962bd706-390702969

COVID-19, Unemployment Compensation, and State Medicaid Expansion ...

Some Workers Losing Jobs and Health Insurance Remain Ineligible for Subsidized Coverage.

Store closed sign.

People who have lost jobs due to COVID-19 and live in states that haven’t expanded Medicaid are at a disadvantage when it comes to accessing affordable health insurance coverage.

The Issue

More than 70 percent of the 7.4 million workers with pre-pandemic employer-based insurance through industries now vulnerable to high rates of unemployment were found to be eligible for some assistance with health insurance (Medicaid or marketplace subsidies) if they lost their jobs. However, eligibility differs significantly between workers in states that have and have not expanded Medicaid.

Authors expand upon earlier work to show how varied levels of unemployment insurance provided through the Federal Pandemic Unemployment Compensation program affects eligibility for subsidized coverage.

Key Findings

Authors find that whether unemployment compensation is included in determining eligibility for Medicaid and Affordable Care Act (ACA) marketplace subsidies affects workers living in states that expanded Medicaid differently than those living in states that do not.

  • If the additional federal unemployment compensation was not used to determine eligibility for health insurance assistance, 78 percent of expansion state workers in the most vulnerable industries would be eligible for assistance compared to 59 percent of their counterparts in the 15 nonexpansion states.

  • Under current law, more than 70 percent of expansion and nonexpansion state workers with pre-pandemic employer-based insurance through industries now vulnerable to high rates of unemployment would be eligible for some assistance with health insurance if they lost their jobs.

Conclusion

The current limits on marketplace subsidies mean that fewer workers are likely to be eligible for financial assistance in getting or maintaining health insurance coverage. At the same time, additional funds could help them meet other pressing needs. This research suggests that eligibility for financial assistance above 400 percent of the federal poverty level under current rules would address this problem.

About the Urban Institute

The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. Visit the Urban Institute’s Health Policy Center for more information specific to its staff and its recent research.  

 

 

 

Reducing COVID-19 Deaths In Nursing Homes: Call To Action

https://www.healthaffairs.org/do/10.1377/hblog20200522.474405/full/?utm_source=Newsletter&utm_medium=email&utm_content=COVID-19%3A+Reducing+Deaths+In+Nursing+Homes%2C+Effective+Multilateralism%3B+Surprise+Out-Of-Network+Bills+For+Ambulance+Transportation+And+Ambulatory+Surgery+Centers&utm_campaign=HAT+5-27-20

Reducing COVID-19 Deaths In Nursing Homes: Call To Action | Health ...

Nursing homes are a hidden and frequently forgotten part of our health care system. They are now under attack by the COVID-19 pandemic: residents are dying, families are disconnected from their loved ones, and staff are sick and overwhelmed by work and the grief of losing so many patients in such a short time. Our state, Massachusetts, is one of the hardest-hit by COVID-19, with over 3,600 deaths and counting in nursing homes, or almost 10 percent of the nursing home population. Over 60 percent of all COVID-19-related deaths in Massachusetts are in nursing homes, one of six states where nursing home residents comprise over 50 percent of COVID-19-related deaths.  The COVID-19 pandemic is exposing years of neglect and chronic underfunding of nursing homes.  

Over 85 percent of the almost 400 nursing homes in Massachusetts currently report two or more cases of COVID-19 among residents or staff.  Emerging data make it abundantly clear that the nursing home environment is highly conducive to the rapid spread of COVID-19, and nursing home residents are among the most susceptible to severe illness and death.  Urgent and decisive action is required to reduce mortality among frail and vulnerable seniors in nursing homes. 

The New England Geriatrics Network (NEGN) is a group of geriatricians, geriatric psychiatrists, nurse practitioners, and others interested in improving care of older adults, that recently convened a Nursing Home Work Group of members interested in improving nursing home care.  We write to share our collective experiences and to reflect on some innovative and promising initiatives adopted in our state.

Success in reducing COVID-19-related morbidity and mortality in the nursing home setting requires urgent action in three areas: 1) enhancing infection control with an individualized plan for each nursing home that incorporates both regulatory guidance and current literature and is feasible to implement; 2) ensuring necessary resources to implement infection control plans, especially adequate staff, training, personal protective equipment (PPE), COVID-19 testing, creation of units for COVID-19 positive patients, and access to onsite ancillary services (labs, imaging, intravenous (IV) management); 3) mirroring the federal Coronavirus Commission for Safety and Quality in Nursing Homes by establishing state-level task forces focused on improving communication and collaboration between nursing homes and families, health care providers (hospitals, health systems, home health agencies, physician organizations), and government agencies.

Although the federal government has offered guidance on infection control in nursing homes, most efforts to manage the pandemic are initiated and managed at the state level.  As a result, there is significant variability in the response. For example, until the federal government recently mandated it, fewer than half of the states reported infection rates and deaths in nursing homes.  Massachusetts implemented several key initiatives that may serve as a model for how to limit COVID-19 epidemic in nursing homes.

Recommendation #1: Operationalizing Effective Infection Control

The only way to reduce COVID-19 deaths is to universally implement effective infection control programs in every nursing home.  The Centers for Disease Control and Prevention (CDC), state agencies like the Massachusetts Department of Public Health, and medical specialty societies have issued checklists and guidance for managing COVID-19 infections in nursing homes. The core challenge is the diversity of the nursing homes, each varying structurally in layout and room design, financially in resources and reserves, and organizationally in staffing and medical leadership. Nationally, 39 percent of nursing homes had deficiencies related to infection control in 2017, including 30 percent of Massachusetts nursing homes.  Each nursing home must create and implement a COVID-19 control plan, review it regularly with public health officials, and allow site visits to validate performance.  A truly collaborative effort will empower and support nursing homes to make required changes, maintain transparency, uphold accountability, and save lives. 

Our colleagues working in Massachusetts nursing homes continue to directly observe ongoing issues with infection control, despite the state’s best efforts to address the pandemic.  In late April, a colleague rounding at a nursing home with known COVID-19 cases found COVID-19-positive, test pending, and COVID-19-free residents sitting together in a communal area. Nurses were wearing varying levels of PPE, some in gowns and masks, and only some with face shields.

Massachusetts recently enhanced its plan to manage COVID-19 in nursing homes by allocating up to $130 million in additional funding to support infection control, staffing, and PPE. Part of the plan is 28-point audit tool to evaluate the strength of each nursing home’s plan, which will be assessed through site visits by state inspectors to every nursing home in the state either every two or four weeks (depending on initial audit results) through the end of June.  Nursing homes can qualify for up to a 50 percent increase over their baseline Medicaid (MassHealth) reimbursement by demonstrating adherence to an effective infection control plan. Facilities failing to implement effective plans can face serious penalties starting with reduced bonus funding and extending to receivership, termination from the state Medicaid program and even forced closure.

In addition to a clear and transparent approach to audits, the state is providing access to infection control expertise to enhance the ability of nursing homes to execute effective infection control plans.  A statewide infection control command center is being led by the nursing home trade organization Massachusetts Senior Care Association (MSCA), along with a senior care and housing organization, Hebrew Senior Life, and others.

Comprehensive infection control plans may require dedicated units for COVID-19-infected patients, important for preventing spread of the infection within nursing homes and for treating COVID-19-positive patients needing inpatient nursing and rehabilitation.  Massachusetts made this a focus of the first phase of its approach to managing COVID-19 in nursing homes.  As of May 1, 2020, six nursing homes have been fully converted to COVID-only facilities, and more than 80 nursing homes have dedicated in-house COVID units.  The state accelerated the creation of these facilities with increased Medicaid payment rates for the care of patients with COVID-19. This has helped offset revenue loss related to decreased post-acute care admissions due to a decrease in elective procedures.

Recommendation #2: Nursing Homes Must Have Adequate Resources For Patient Care Including Staffing, PPE, Testing, And Onsite Ancillary Services

The lack of infection control resources reflects longstanding gaps in the nursing home setting which have been greatly exacerbated by the current pandemic. The state is providing additional Medicaid payments to nursing homes, as mentioned above. These resources are needed to improve care and infection control.

Staffing

In mid-April, as the surge in COVID-19 cases accelerated in Massachusetts, 40 percent of nursing home positions were vacant in the state  As the pandemic spread, many staff became unavailable due to infection, increased risk related to underlying comorbidities, or family responsibilities.  Many nursing home staff work on a per diem basis, and often lack paid sick leave. Until recently, transportation and paid housing solutions put in place for hospital staff had not been extended to them.

The staffing shortage threatens the health of all residents on short-staffed units and reveals how human contact is fundamental to good nursing home care.  A member of our group recently visited a nursing home where staffing on a 30-resident unit was reduced to one nurse and one nurse’s aide.  Isolation is a cornerstone of fighting COVID-19, but with family and volunteers not permitted in nursing homes, he reported seeing increased dehydration, falls, and poor hygiene as staff struggled to hand-feed residents and provide personal care.  In addition, family members may wait days to hear back about their loved one from overwhelmed nursing home staff.  This lack of communication is a huge barrier to high quality care, especially for patients needing frequent symptom management, such as those in hospice care. 

Massachusetts is taking several actions to alleviate staffing shortages.  The state offered a $1,000 bonus for new nursing home staff, and an online portal was created to match nursing homes with job seekers and volunteers.  The state is making available rapid response teams including nurses, emergency medical technicians (EMTs), and others that can be temporarily deployed for a few days to assist challenged nursing homes. National Guard units are available for non-clinical support, as well as staff from temporary staffing agencies contracted by the state.  Private sector efforts include a collaboration between Massachusetts Senior Care Association, the MIT COVID-19 Policy Alliance, and Monster.com to offer free staffing listings on Monster’s recruiting website.

Personal Protective Equipment

As with all other health care settings, PPE shortages are an ongoing challenge, and states must do more to help.  In Massachusetts, as of May 19, 2020, the state has distributed almost 350,000 N95 masks, over 780,000 masks, and 708,000 pairs of gloves to nursing homes.  However, this is not enough to provide for all of the needs of the nearly 400 nursing homes in the state, which must still rely on their own supply chains, including new purchasing collaboratives, to help facilities gain PPE access. Providing PPE to family members and volunteers could help mitigate some of the impact of extreme staffing shortages.

Testing For COVID-19

Access to routine testing can improve infection control and identify patients at risk of decline.  Testing should not be limited to only those with symptoms.  In early April, a nursing home in Wilmington, MA underwent facility-wide screening.  Over 50 percent of residents without symptoms tested positive for COVID-19, and within two weeks, 25 residents had died.  Universal testing of residents and staff should be performed as quickly as possible, and routine testing must be available to evaluate symptomatic nursing home residents.  The state of Massachusetts now requires every nursing home to test all residents and staff as a prerequisite to receiving any supplemental COVID-19 funding.  If the nursing home cannot arrange testing, the state will continue to supply National Guard mobile testing teams and dispense testing kits directly to nursing homes.  For nursing homes where testing may not be readily available, or if there are already significant numbers of COVID-19 infections, it should be presumed that all residents and staff are infected, and PPE and other universal infection control measures should be implemented.

Ancillary Services

One overlooked but essential resource is access to ancillary services.  Most nursing homes rely on external companies to provide onsite services, including laboratory tests (e.g. blood tests, urinalysis), to start IVs and provide portable imaging (X-Ray, ultrasound), and to stock medications.  Many of these companies also face challenges with staff and PPE and have decreased services from daily visits to once or twice a week.  As a result, families who want their loved one diagnosed and treated in the nursing home (e.g. chest x-ray, labs for possible pneumonia, followed by IV insertion for antibiotics), or who need urgent assessments, COVID-19 related or not, must decide whether to transfer their family member to the emergency department. One solution is redeploying EMTs, now freed up from transport for elective procedures, to draw labs and start IVs in nursing homes to keep patients where they feel safe and comfortable, and to avoid further stress on over-burdened emergency departments.

Recommendation #3: Establishing COVID-19 Control Task Forces

COVID-19 has forced our society into isolation, but communication and collaboration are essential for successfully fighting pandemics.  We strongly recommend each state create a task force for COVID-19 pandemic control in nursing homes for a minimum of two years, to bring together relevant governmental agencies (Public Health, Elder Affairs or Aging agency, Emergency Management, Medicaid, and others) and other key stakeholders, which include nursing home clinicians, the nursing home industry, ancillary services companies, hospitals, physician groups, and nursing home residents and family members. Local and regional task forces should collaborate to support links between nursing homes and local health care systems and ensure that nursing homes have effective communications with family members and clinicians providing care.  Collaboration with state governments and nursing home leadership in other states is also essential, as many staff, clinicians, and family members travel across state lines.

Task Forces must initially focus on ensuring effective infection control and making resources available to reduce the morbidity and mortality of COVID-19 on nursing home residents and those needing post-acute care. They also should anticipate and plan for the inevitable changes and continued need for nursing home care in the wake of the COVID-19 pandemic.

In Summary

Nursing homes should receive necessary support as an integral and most vulnerable part of the continuum of care. The population is aging, and the need for high quality long-term care, especially for those who lack family or financial resources, is growing rapidly.  Now is the time to ensure the safety and continued viability of this vital health care setting.

Authors’ Note: This call to action was written by the co-authors above on behalf of The New England Geriatrics Network (NEGN) Nursing Home Work Group.

 

 

 

 

All 50 states have partially reopened; U.S. death toll surpasses 90,000

https://www.washingtonpost.com/nation/2020/05/20/coronavirus-update-us/?utm_campaign=wp_post_most&utm_medium=email&utm_source=newsletter&wpisrc=nl_most

NC coronavirus update May 18: Wake County leaders meet to discuss ...

Ready or not, the United States is reopening. All 50 states have started easing coronavirus-related restrictions — even though many of them do not meet federal benchmarks — leading public health experts to warn that a new surge of infections could be imminent.

As the U.S. death toll surpassed 90,000, White House officials continued to defend the push to reopen and optimistically predicted a swift economic recovery. As part of the focus on states’ efforts to revive their economies, Vice President Pence on Wednesday traveled to Florida while Trump was set to host the governors of Arkansas and Kansas at the White House.

Here are some significant developments:

  • Trump ramped up his rhetoric against China, claiming on Twitter that the nation’s “incompetence” was responsible for “this mass Worldwide killing!” Secretary of State Mike Pompeo also denounced China as a “brutal authoritarian regime” and described its relationship with the director of the World Health Organization as “troubling.”
  • A worker at a mink farm in the Netherlands may have contracted the novel coronavirus from an animal there, the country’s agricultural minister said. If confirmed, this is would be first recorded incident of animal-to-human transmission. 
  • A church in Houston and another in Georgia are closing for a second time after faith leaders and congregants tested positive for the virus shortly after the two churches reopened.
  • The president drew criticism for saying Tuesday it’s “a badge of honor” that America leads the world with more than 1.5 million confirmed cases of the novel coronavirus because “it means our testing is much better.” The United States has more than 30 percent of the world’s known coronavirus infections but accounts for less than 5 percent of the global population.
  • The Centers for Disease Control and Prevention laid out a detailed, delayed road map for reopening schools, child-care facilities, restaurants and mass transit, weeks after governors began opening states on their own terms.
  • The president privately expressed opposition to extending unemployment benefits for workers affected by the pandemic.

 

 

 

 

Medicaid Providers At The End Of The Line For Federal COVID Funding

https://khn.org/news/medicaid-providers-at-the-end-of-the-line-for-federal-covid-funding/

Medicaid Providers At The End Of The Line For Federal COVID ...

Casa de Salud, a nonprofit clinic in Albuquerque, New Mexico, provides primary medical care, opioid addiction services and non-Western therapies, including acupuncture and reiki, to a largely low-income population.

And, like so many other health care providers that serve as a safety net, its revenue — and its future — are threatened by the COVID-19 epidemic.

“I’ve been working for the past six weeks to figure out how to keep the doors open,” said the clinic’s executive director, Dr. Anjali Taneja. “We’ve seen probably an 80% drop in patient care, which has completely impacted our bottom line.”

In March, Congress authorized $100 billion for health care providers, both to compensate them for the extra costs associated with caring for patients with COVID-19 and for the revenue that’s not coming in from regular care. They have been required to stop providing most nonemergency services, and many patients are afraid to visit health care facilities.

But more than half that money has been allocated by the Department of Health and Human Services, and the majority of it so far has gone to hospitals, doctors and other facilities that serve Medicare patients. Officials said at the time that was an efficient way to get the money beginning to move to many providers. That, however, leaves out a large swath of the health system infrastructure that serves the low-income Medicaid population and childrenCasa de Salud, for example, accepts Medicaid but not Medicare.

State Medicaid directors say that without immediate funding, many of the health facilities that serve Medicaid patients could close permanently. More than a month ago, bipartisan Medicaid chiefs wrote the federal government asking for immediate authority to make “retainer” payments — not related to specific care for patients — to keep their health providers in business.

“If we wait, core components of the Medicaid delivery system could fail during, or soon after, this pandemic,” wrote the National Association of Medicaid Directors.

So far, the Trump administration has not responded, although in early April it said it was “working rapidly on additional targeted distributions” for other providers, including those who predominately serve Medicaid patients.

In an email, the Centers for Medicare & Medicaid Services said officials there will “continue to work with states as they seek to ensure continued access to care for Medicaid beneficiaries through and beyond the public health emergency.”

CMS noted that states have several ways of boosting payments for Medicaid providers, but did not directly answer the question about the retainer payments that states are seeking the authority to make. Nor did it say when the funds would start to flow to Medicaid providers who do not also get funding from Medicare.

The delay is frustrating Medicaid advocates.

“This needs to be addressed urgently,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families in Washington, D.C. “We are concerned about the infrastructure and how quickly it could evaporate.”

In the administration’s explanation of how it is distributing the relief funds, Medicaid providers are included in a catchall category at the very bottom of the list, under the heading “additional allocations.”

“To not see anything substantive coming from the federal level just adds insult to injury,” said Todd Goodwin.

He runs the John F. Murphy Homes in Auburn, Maine, which provides residential and day services to hundreds of children and adults with developmental and intellectual disabilities. He said his organization — which has already furloughed almost 300 workers and spent more than $200,000 on COVID-related expenses including purchases of essential equipment such as masks and protective equipment that will not be reimbursable — has not been eligible for any of the various aid programs passed by Congress. It gets most of its funding from Medicaid and public school systems.

The organization has tapped a line of credit to stay afloat. “But if we’re not here providing these services, there’s no Plan B,” he said.

Even providers who largely serve privately insured patients are facing financial distress. Dr. Sandy Chung is CEO of Trusted Doctors, which has about 50 physicians in 13 offices in the Northern Virginia suburbs around Washington, D.C. She said about 15% of its funding comes from Medicaid, but the drop off in private and Medicaid patients has left the group “really struggling.”

“We’ve had to furlough staff, had to curtail hours, and we may have to close some locations,” she said.

Of special concern are children because Medicaid covers nearly 40% of them across the county. Chung, who also heads the Virginia chapter of the American Academy of Pediatrics, said that vaccination rates are off 30% for infants and 75% for adolescents, putting them and others at risk for preventable illnesses.

The biggest rub, she added, is that with the economy in free fall, more people will qualify for Medicaid coverage in the coming weeks and months.

“But if you don’t have providers around anymore, then you will have a significant mismatch,” she said.

Back in Albuquerque, Taneja is working to find whatever sources of funding she can to keep the clinic open. She secured a federal loan to help cover her payroll for a couple of months, but worries what will happen after that. “It would kill me if we’ve survived 15 years in this health care system, just to not make it through COVID,” she said.

 

 

 

 

States brace for ‘nearly certain’ Medicaid budget shortfalls amid COVID-19

https://www.healthcaredive.com/news/states-brace-for-nearly-certain-medicaid-budget-shortfalls-amid-covid-19/578120/

Coronavirus updates: Virus reaches all 50 states, stock futures fall

Dive Brief:

  • Most states with budget projections expect Medicaid shortfalls due to rising spending as more people lose jobs and enroll into the safety net insurance for low-income Americans due to the COVID-19 pandemic, according to a new Kaiser Family Foundation survey.
  • Almost all states with enrollment projections and more than half with spending projections expect program growth to surpass pre-pandemic estimates. Nearly all states anticipate growth will accelerate even more in the 2021 fiscal year, KFF found. As a result of that growth, 17 of 19 states with budget projections report a shortfall is “nearly certain” or “likely” for the upcoming fiscal year.
  • The survey comes as Congress once again considers raising the federal match rate for Medicaid in the $3 trillion Health and Economic Recovery Omnibus Emergency Solutions Act, passed by the House of Representatives on Friday.​

Dive Insight:

Medicaid is often the top line spending item in state budgets, sending states scrambling for ways to reduce spend in the safety net health insurance program, including controversial block grants for funding.

At the start of the 2020 fiscal year, states anticipated modest Medicaid spending growth, and flat enrollment growth due to the strong economy. That forecast quickly shifted as the coronavirus spread in the U.S., which lost some 21 million jobs in April as businesses shutter their doors in compliance with stay-at-home orders, sending the unemployment rate to 15%.  

Because the U.S. generally couples coverage to employment, skyrocketing job loss could make an estimated 17 million people newly eligible for Medicaid and 6 million eligible for subsidies in the Affordable Care Act marketplaces by January 2021.

Medicaid officials from 38 states shared their budget projections with KFF for the survey. States that did not respond were still gathering data about the coronavirus or didn’t have updated enrollment or spending projections for the 2020 or 2021 fiscal years, KFF researchers Robin Rudowitz and Elizabeth Hinton said.

Thirty-two of 34 states with enrollment projections think enrollment will exceed initial projections in 2020, and 30 of 31 states anticipate that growth in 2021 will outpace the current fiscal year.

States are more mixed on spending projections. Over half of states with projections, 18 of 32, expect 2020 Medicaid spending to exceed pre-pandemic estimates. Eight states anticipate no change, and the remaining six project slightly lowered spending due to lower healthcare utilization as non-essential services have largely ground to a halt.

State Medicaid officials are more in lockstep when it comes to 2021 spending projections. Nearly all states with projections — 29 of 30 — think Medicaid spending rates in 2021 will increase over 2020.

Without greater support from the federal government, the survey hints states will face significant spending cuts for Medicaid for the upcoming fiscal year, which begins July 1 for most states. Multiple groups, including the National Governors Association and the National Association of State Medicaid Directors, have called for a higher federal match rate.

One of the first legislative packages designed to mitigate the fallout of COVID-19, the Families First Coronavirus Response Act passed March 18, authorized a 6.2 percentage point increase in the rate for Medicaid if states meet certain requirements. States can’t increase premiums or restrict eligibility standards and must cover COVID-19 testing and treatment without cost-sharing.

The HEROES Act passed by Democrats in the House on Friday would increase the match rate by 14 percentage points from July 1, 2020, through June 30, 2021, along with benchmarking an additional $100 billion for providers.

However, Senate Majority Leader Mitch McConnell, R-Ky., and President Donald Trump have said they’re in no rush to pass another round of legislation adding to the more than $3 trillion Congress has approved so far.

 

 

 

 

Another 3 million Americans filed for unemployment last week

https://www.axios.com/jobless-claims-coronavirus-3-million-460364c8-be73-437c-b99c-fa7d75aad87e.html?stream=top&utm_source=alert&utm_medium=email&utm_campaign=alerts_all

Data: U.S. Employment and Training Administration via FRED; Chart: Andrew Witherspoon/Axios

Data: U.S. Employment and Training Administration via FRED; Chart: Andrew Witherspoon/Axios

Another 2.98 million Americans filed for unemployment last week, the Labor Department said on Thursday.

Why it matters: The coronavirus is still forcing a historically high number of Americans out of work. In two months alone, more than 36 million people have filed jobless claims.

Between the lines: The pace of new applications has slowed from its peak in March, but the weekly numbers are still way higher than before businesses shuttered to contain the outbreak.

  • There are more jobless workers that haven’t been able to get their application through. State unemployment offices are racing to get through an avalanche of unemployment filings — with states like New York processing more claims in the past few months than they have in years.
  • Measuring the backlog is “like trying to measure the ocean, it’s constantly moving,” New York Labor Department commissioner Roberta Reardon said in a press call yesterday.
  • While more Americans than ever before are eligible for unemployment, including gig workers, some states are just beginning to scale up to accept those applications.

By the numbers: The total number of people continuing to receive unemployment benefits — after initially applying — rose, bringing the total to a record 22.8 million.

  • A decrease in this figure would be an indication that Americans are returning back to work.

The bottom line: Goldman Sachs estimates the unemployment rate will hit 25%, matching the peak level of joblessness during the Great Depression.

 

Window of Opportunity is Closing for Coronavirus Response

https://www.axios.com/rick-bright-testimony-opening-statement-6817ae7a-5196-4357-b83c-d3ff96990efd.html?stream=health-care&utm_source=alert&utm_medium=email&utm_campaign=alerts_healthcare

Window of opportunity – definition and meaning – Market Business News

A top vaccine doctor who was ousted from his position in April is expected to testify Thursday that the Trump administration was unprepared for the coronavirus, and that the U.S. could face the “darkest winter in modern history” if it doesn’t develop a national coordinated response, according to prepared testimony first obtained by CNN.

The big picture: Rick Bright, the former head of the Biomedical Advanced Research and Development Authority (BARDA), will tell Congress that leadership at the Department of Health and Human Services ignored his warnings in January, February and March about a potential shortage of medical supplies.

  • He will testify that HHS “missed early warning signals” and “forgot important pages from our pandemic playbook” early on — but that “for now, we need to focus on getting things right going forward.”
  • Bright’s testimony also reiterates claims from a whistleblower report he filed last week that alleges he was ousted over his attempts to limit the use of hydroxychloroquine — an unproven drug touted by President Trump — to treat the coronavirus.

What he’s saying: Bright will testify he urged HHS to ramp up production of
masks, respirators and medical supplies as far back as January. Those warnings were dismissed, Bright says, and he was “cut out of key high-level meetings to combat COVID-19.”

  • “I continue to believe that we must act urgently to effectively combat this deadly disease. Our window of opportunity is closing. If we fail to develop a national coordinated response, based in science, I fear the pandemic will get far worse and be prolonged, causing unprecedented illness and fatalities.”

Bright will call for a national strategy to combat the virus, including “tests that are accurate, rapid, easy to use, low cost, and available to everyone who needs them.”

  • “Without clear planning and implementation of the steps that I and other experts have outlined, 2020 will be darkest winter in modern history.”

Read Bright’s prepared statement.

 

 

 

 

The latest in the U.S.

https://www.axios.com/newsletters/axios-vitals-72173ec6-3383-4391-afbb-a5ed682e5d7a.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

COVID-19 in the U.S.

As of May 12, 2020, 11pm EDT

Deaths       Confirmed Cases

82,376           1,369,574

Trump and some top aides question accuracy of coronavirus death ...

 

The U.S. will “without a doubt” have more coronavirus infections and deaths in the fall and winter if effective testing, contact tracing and social distancing measures are not scaled up to adequate levels, NIAID director Anthony Fauci testified on Tuesday.

  • He also said that the “consequences could be really serious” for states and cities that reopen without meeting federal guidelines.

Sen. Mitt Romney (R-Utah) criticized the Trump administration’s coronavirus testing coordinator Adm. Brett Giroir at a Senate hearing Tuesday, accusing him of framing U.S. testing data in a politically positive light: “I find our testing record nothing to celebrate whatsoever.”

Millions of Americans are risking their lives to feed us and bring meals, toiletries and new clothes to our doorsteps — but their pay, benefits and working conditions do not reflect the dangers they face at work, Axios’ Erica Pandey reports.

House Democrats released Tuesday their phase 4 $3 trillion coronavirus relief proposal that would provide billions of additional aid to state and local governments, hospitals and other Democratic priorities.

The American Federation of Teachers launched several capstone lesson plans Tuesday to help K-12 teachers measure student progress during school closures and overcome the challenges of a remote learning setting.

Grocery staples in the U.S. cost more in the last month than in almost 50 years, according to new data out Tuesday from the U.S. Bureau of Labor Statistics.

A new study by economists at the University of Illinois, Harvard Business School, Harvard University and the University of Chicago projects that more than 100,000 small businesses have permanently closed since the coronavirus pandemic was declared in March, the Washington Post reports.

 

 

 

 

 

Coronavirus likely forced 27 million off their insurance

https://www.axios.com/newsletters/axios-vitals-72173ec6-3383-4391-afbb-a5ed682e5d7a.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

The coronavirus pandemic is hitting Main Street and triggering ...

Roughly 27 million people have likely have lost job-based health coverage since the coronavirus shocked the economy, according to new estimates from the Kaiser Family Foundation.

Why it matters: Most of these people will be able sign up for other sources of coverage, but millions are still doomed to be uninsured in the midst of a pandemic, Axios’ Bob Herman reports.

By the numbers: For the 27 million people who are losing their job-based coverage, about 80% have other options, said Rachel Garfield, a health policy expert at the Kaiser Family Foundation and lead author of the report.

  • Roughly half are eligible for Medicaid or the Children’s Health Insurance Program.
  • Another third are eligible for subsidized health plans on the Affordable Care Act’s marketplaces.
  • The remaining 20% are pretty much out of luck because they live in a state that didn’t expand Medicaid or are ineligible for other kinds of subsidized coverage.
  • House Speaker Nancy Pelosi’s latest coronavirus relief bill would fully subsidize the cost of maintaining an employer plan through COBRA — an option that would otherwise be prohibitively expensive for many people. But that’s a long way from becoming law.

The bottom line: The coronavirus is blowing up health insurance at a time when people need it most.