Small hospitals’ bailout concerns

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Country Closures: Rural Communities Adapt As More Hospitals Shut Down

Congress is about to provide $100 billion for hospitals and other health care providers to cope with the fallout from the coronavirus, but small hospitals have no idea how to access those funds — and many need the money immediately, Axios’ Bob Herman reports.

What they’re saying: “A lot of rural hospitals out there need a cash infusion today,” Alan Morgan, CEO of the National Rural Health Association, told Axios. “How is it going to happen? What is the process? There are way more questions than answers.”

Details: The stimulus bill says “the Secretary of Health and Human Services shall, on a rolling basis, review applications and make payments” to hospitals and other providers, out of a $100 billion fund.

  • HHS did not respond to questions about how that process would work.

Between the lines: Many hospitals are part of large, profitable systems that benefit from their area’s demographics. The coronavirus will cause them financial distress, but they are not in danger of going under.

  • Rural and safety net hospitals, which treat disproportionate amounts of older and low-income patients, have a lot less wiggle room to call off elective procedures as they wait for a coronavirus surge.
  • Many small hospitals can’t get new loans from banks and could miss payroll as soon as next week.

The bottom line: Bob asked Morgan how this process was supposed to work. “I don’t know,” he said, “and we are greatly concerned.”

 

 

 

 

Experts agree that Trump’s coronavirus response was poor, but the US was ill-prepared in the first place

https://theconversation.com/experts-agree-that-trumps-coronavirus-response-was-poor-but-the-us-was-ill-prepared-in-the-first-place-133674?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20March%2017%202020%20-%201565314971&utm_content=Latest%20from%20The%20Conversation%20for%20March%2017%202020%20-%201565314971+Version+A+CID_6ce2ffeb273f535ccdcb368c4649a7ee&utm_source=campaign_monitor_us&utm_term=Experts%20agree%20that%20Trumps%20coronavirus%20response%20was%20poor%20but%20the%20US%20was%20ill-prepared%20in%20the%20first%20place

As the coronavirus pandemic exerts a tighter grip on the nation, critics of the Trump administration have repeatedly highlighted the administration’s changes to the nation’s pandemic response team in 2018 as a major contributor to the current crisis. This combines with a hiring freeze at the Centers for Disease Control and Prevention, leaving hundreds of positions unfilled. The administration also has repeatedly sought to reduce CDC funding by billions of dollars. Experts agree that the slow and uncoordinated response has been inadequate and has likely failed to mitigate the coming widespread outbreak in the U.S.

As a health policy expert, I agree with this assessment. However, it is also important to acknowledge that we have underfunded our public health system for decades, perpetuated a poorly working health care system and failed to bring our social safety nets in line with other developed nations. As a result, I expect significant repercussions for the country, much of which will disproportionately fall on those who can least afford it.

Decades of underfunding

Spending on public health has historically proven to be one of humanity’s best investments. Indeed, some of the largest increases in life expectancy have come as the direct result of public health interventions, such as sanitation improvements and vaccinations.

Even today, return on investments for public health spending is substantial and tends to significantly outweigh many medical interventions. For example, one study found that every US$10 per person spent by local health departments reduces infectious disease morbidity by 7.4%.

However, despite their importance to national well-being, public health expenditures have been neglected at all levels. Since 2008, for example, local health departments have lost more than 55,000 staff. By 2016, only about 133,000 full-time equivalent staff remained. State funding for public health was lower in 2016-2017 than in 2008-2009. And the CDC’s prevention and public health budget has been flat and significantly underfunded for years. Overall, of the more than $3.5 trillion the U.S. spends annually on health care, a meager 2.5% goes to public health.

Not surprisingly, the nation has experienced a number of outbreaks of easily preventable diseases. Currently, we are in the middle of significant outbreaks of hepatitis A (more than 31,000 cases), syphilis (more than 35,000 cases), gonorrhea (more than 580,000 cases) and chlamydia (more than 1,750,000 cases). Our failure to contain known diseases bodes ill for our ability to rein in the emerging coronavirus pandemic.

Failures of health care systems

Yet while we have underinvested in public health, we have been spending massive and growing amounts of money on our medical care system. Indeed, we are spending more than any other country for a system that is significantly underperforming.

To make things worse, it is also highly inequitable. Yet, the system is highly profitable for all players involved. And to maximize income, both for- and nonprofits have consistently pushed for greater privatization and the elimination of competitors.

As a result, thousands of public and private hospitals deemed “inefficient” because of unfilled beds have closed. This eliminated a significant cushion in the system to buffer spikes in demand.

At any given time, this decrease in capacity does not pose much of a problem for the nation. Yet in the middle of a global pandemic, communities will face significant challenges without this surge capacity. If the outbreak mirrors anything close to what we have seen in other countries, “there could be almost six seriously ill patients for every existing hospital bed.” A worst-case scenario from the same study puts the number at 17 to 1. To make things worse, there will likely be a particular shortage of unoccupied intensive care beds.

Of course, the lack of overall hospitals beds is not the most pressing issue. Hospitals also lack the levels of staffing and supplies needed to cope with a mass influx of patients. However, the lack of ventilators might prove the most daunting challenge.

Limits of the overall social safety net

While the U.S. spends trillions of dollars each year on medical care, our social safety net has increasingly come under strain. Even after the Affordable Care Actalmost 30 million Americans do not have health insurance coverage. Many others are struggling with high out-of-pocket payments.

To make things worse, spending on social programs, outside of those protecting the elderly, has been shrinking, and is significantly smaller than in other developed nations. Moreover, public assistance is highly uneven and differs significantly from state to state.

And of course, the U.S. heavily relies on private entities, mostly employers, to offer benefits taken for granted in other developed countries, including paid sick leave and child care. This arrangement leaves 1 in 4 American workers without paid sick leave, resulting in highly inequitable coverage. As a result, many low-income families struggle to make ends meet even when times are good.

Can the US adapt?

I believe that the limitations of the U.S. public health response and a potentially overwhelmed medical care system are likely going to be exacerbated by the blatant limitations of the U.S. welfare state. However, after weathering the current storm, I expect us to go back to business as usual relatively quickly. After all, that’s what happened after every previous pandemic, such as H1N1 in 2009 or even the 1918 flu epidemic.

The problems are in the incentive structure for elected officials. I expect that policymakers will remain hesitant to invest in public health, let alone revamp our safety net. While the costs are high, particularly for the latter, there are no buildings to be named, and no quick victories to be had. The few advocates for greater investments lack resources compared to the trillion-dollar interests from the medical sector.

Yet, if altruism is not enough, we should keep reminding policymakers that outbreaks of communicable diseases pose tremendous challenges for local health care systems and communities. They also create remarkable societal costs. The coronavirus serves as a stark reminder.

 

 

Seattle Coronavirus Care: Short in Staff, Supplies and Space

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At ground zero of America’s coronavirus outbreak, Seattle is overwhelmed by patients needing care. Social distancing and persistent hand washing is no longer enough. “The next step is to start thinking about alternate care systems.”

Amid the first signs that the novel coronavirus was spreading in the Seattle area, a senior officer at the University of Washington Medical Center sent an urgent note to staffers.

“We are currently exceptionally full and are experiencing some challenges with staffing,” Tom Staiger, UW Medical Center’s medical director, wrote on Feb. 29. He asked hospital staff to “expedite appropriate discharges asap,” reflecting the need for more beds.

That same day, health officials announced King County’s — and the nation’s — first death from the coronavirus. Now as cases of virus-stricken patients suffering from COVID-19 multiply, government and hospital officials are facing the real-life consequences of shortcomings they’ve documented on paper for years.

Medical supplies have run low. Administrators are searching for ways to expand hospital bed capacity. Health care workers are being asked to work extra shifts as their peers self-isolate.

And researchers this week made stark predictions for COVID-19’s impact on King and Snohomish counties, estimating 400 deaths and some 25,000 infections by April 7 without social-distancing measures.

“If you start doing that math in your head, based on every person who was infected infecting two other people, you can see every week you have a doubling in the number of new cases,” state health oficer Dr. Kathy Lofy said.

Hand-washing, staying home from work and other measures were no longer enough to sufficiently slow the virus, Lofy said.

Hospital administrators are rapidly changing protocols as the outbreak stresses the system, while frontline health care workers are beginning to feel the effects of disruptions to daily life. UW Medicine on Thursday told employees it would begin postponing elective procedures, beginning March 16.

“We’ve seen what has happened in other countries where they’ve had really rapid spread. The health care system has become overwhelmed,” Lofy said. “We want to do everything we can to prevent that from happening here.”

“We’re Always Full”

King and Snohomish counties offer some 4,900 staffed hospital beds, of which about 940 are used for critical care, according to the researchers — with the Institute for Disease Modeling, the Bill & Melinda Gates Foundation and the Fred Hutchinson Cancer Research Center — who modeled the outbreak’s potential growth. “… This capacity may quickly be filled,” they wrote.

Some of Seattle’s largest hospitals were already near capacity before the outbreak. Harborview Medical Center in downtown Seattle operated at 95 percent of its capacity in 2019, based on its licensed 413 beds and the days of patient care it reported to the Department of Health.

Of 81 hospitals that reported data for all of 2019, excluding psychiatric hospitals, the median hospital operated at 50 percent of its licensed capacity, according to a Seattle Times analysis. Many hospitals staff fewer beds than the maximum their license allows for, so the actual occupancy rate is likely higher.

Katharine Liang, a psychiatry resident physician who works rotations for Seattle-area hospitals, said requests for UW Medicine staffers to discharge patients in a timely fashion are not uncommon as administrators seek extra beds.

“The safety net hospitals, we’re always full,” Liang said, referring to medical centers that care for patients without insurance or means to pay.

Susan Gregg, a spokeswoman for UW Medicine, which operates UW Medical Center, Harborview Medical Center, Valley Medical Center and Northwest Hospital, said that each hospital had a surge-capacity plan being adapted for the outbreak.

“Our daily planning sessions monitor our available beds, supply usage and human resources,” Gregg said in a statement.

While Washington state has a robust system for detecting and monitoring infectious diseases, it has struggled to build the capacity to respond to emergencies like the coronavirus outbreak, according to a review of public data and interviews.

On a per-person basis, the state lags most others in nurses and hospital rooms designed to isolate patients with infectious, airborne diseases, according to a nationwide index of health-security measures.

The U.S. Centers for Disease Control and Prevention launched this initiative — called the National Health Security Preparedness Index — in 2013 to comprehensively evaluate the nation’s readiness for public health emergencies.

The state’s greatest strength, according to the index, is in its ability to detect public-health threats and contain them — scoring 8.5 points out of a possible 10, above the national average.

“It’s a leading state now in terms of how testing capabilities are playing out” for COVID-19, said Glen Mays, a professor at the Colorado School of Public Health who directs the index work.

With the scope of the outbreak becoming clear, the focus is turning to an area that is the state’s weakest on the index: providing access to medical care during emergencies.

When it comes to nurses per 100,000 people, Washington state ranked near the bottom — 46th among states and the District of Columbia — in 2018. It ranked 43rd nationally in the number of hospital isolation rooms — commonly referred to as “negative pressure” rooms, which draw in air to prevent an airborne disease from spreading — per 100,000 people and in neighboring states.

“It’s an area of concern,” Mays said of the state’s health care delivery capacity.

This vulnerability is well known to state policymakers. John Wiesman, Washington state’s health secretary, serves on the national advisory committee of the index and has championed its use as a tool for improvement, Mays said. He recalled Washington seeking lessons from other states that have been more successful and building a “medical reserve corps,” another area where the state has lagged.

The state scored 2.5 points for managing volunteers in an emergency in 2013. In 2018, it had improved to just 2.6.

Health Workers Strained

Less than a week after diagnosed cases of COVID-19 grew rapidly in the Seattle area, administrators at several area hospitals had to hunt for additional medical supplies and called for rationing. They also established fast-shifting isolation policies for sick or potentially exposed staffers.

“Hospitals are being very vigilant. If you have the slightest signs of illness, don’t come to work,” said Alexander Adami, a UW Medicine resident, on Monday.

On March 6, UW Medicine directed employees who tested positive for COVID-19, the illness caused by coronavirus, to remain isolated at home for a minimum of seven days after symptoms developed, according to internal UW documents. Hospital workers told workers with symptoms who hadn’t been tested to remain isolated until they were three days without symptoms. Those who tested negative, or had influenza, could return after 24 hours.

Quarantines for sick workers means others must backfill.

“Programs are having to pull residents in other blocks in other hospitals and other clinics to fill gaps,” Adami said. “There simply aren’t enough people.”

School closures further complicate staffing.

Liang, the resident physician who works rotations for several area hospitals, said she had been pulled into an expanded backup pool on short notice to cover shifts.

Liang is the mother of a 1-year-old. On Wednesday, her family’s day care closed, as it typically does when Seattle schools close. Gov. Jay Inslee has ordered all schools in King, Pierce and Snohomish counties to close until late April.

“I’m not really sure what we’re going to do going forward,” Liang said. “My demands at home are increasing, and now, at the same time because of the same problem, my demands at the hospital are increasing as well.”

Adami, a second-year internal medicine resident, said residents were used to taxing hours, and demands had not been much more excessive than usual, but he remained concerned for the future.

“I would be worried about: We eventually get to the point where there are so many health care workers who become sick we have to accept things like saying, All right: Do you have a fever? No? Take a mask and keep working, because there are people to care for,” he said.

One sign of demand: Some hospitals are asking workers at greater risk of COVID-19 to continue in their roles, even after public health officials encouraged people in these at-risk groups among the broader public to stay home.

Staff over the age of 60 “should continue to work per their regular schedules,” a UW Medicine policy statement said. People who are pregnant, immunocompromised or over 60 and with underlying health conditions were “invited to talk to their team leader or manager about any concerns,” noting that hospital workers’ personal protective equipment would minimize exposure risks.

A registered nurse at Swedish First Hill who is over 60 and who has a history of cardiac issues said she told a manager last week of her concern about working with potential or confirmed COVID-19 patients.

She said a manager adjusted her schedule for an initial shift, but couldn’t guarantee that she would be excused from caring for these patients.

Hours later, the nurse said she suffered a cardiac event and was later admitted to another hospital with a stress-induced cardiomyopathy. The nurse did not want to be named for fear of reprisal by Swedish.

“I’m afraid for my life to work in there,” the nurse said. “I don’t think we’re being adequately protected.”

The nurse is now on medical leave.

In a statement, Swedish said it could not comment on an individual caregiver’s specific circumstances, but that employees at a higher risk are able to request reassignment and if it can not be accommodated, they can take a leave of absence.

“Providing a safe environment for our caregivers and patients is always our top priority, but especially during the current COVID-19 outbreak,” according to the statement.

Anne Piazza, senior director of strategic initiatives for the the Washington State Nurses Association said she had heard from a “flood” of nurses with similar concerns.

Additionally, “we are seeing increased demand for nurse staffing and that we do have reports of nurses being required to work mandatory overtime.”

Wuhan was Overwhelmed

China might provide an example of what could happen to the U.S. hospital system if the pace of transmission escalates, according to unpublished work from researchers with Johns Hopkins University, Harvard University and other institutions.

In Wuhan, the people seeking care for COVID-19 symptoms quickly outpaced local hospitals’ ability to keep up, the researchers found. Even after the city went on lockdown in late January, the number of people needing care continued to rise.

Between Jan. 10 and the end of February, physicians served an average of 637 intensive-care unit patients and more than 3,450 patients in serious condition each day.

But by the epidemic’s peak, nearly 20,000 people were hospitalized on any given day. In response, two new hospitals were built to exclusively serve COVID-19 patients; in all, officials dedicated more than 26,000 beds at 48 hospitals for people with the virus. An additional 13,000 beds at quarantine centers were set aside for patients with mild symptoms.

The researchers analyzed what might happen if a Wuhan-like outbreak happened here.

“Our critical-care resources would be overwhelmed,” said Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security who helped lead the study.

“The lesson here, though, is we have an opportunity to learn from their experience and to intervene before it gets to that point.”

Preparing For The Worst

Hospital administrators are stretching to make the most of their staff, avoid burnout and find space for patients flooding into hospitals.

As of Thursday afternoon, there hadn’t been an unusual uptick in hospitals asking emergency responders to divert patients elsewhere, according to Beth Zborowski, a spokeswoman for the Washington State Hospital Association.

Zborowski said administrators are getting creative to deal with shortages of supplies, staff and space, such as potentially hiring temporary workers.

The state is trying to reduce regulations to help scale up staffing.

The state health department’s Nursing Commission said last Friday it would give “top priority” to reviewing applications for temporary practice permits for nurses to help during the COVID-19 crisis.

After the governor’s emergency proclamation, the Department of Health also said it was allowing volunteer out-of-state health practitioners who are licensed elsewhere to practice without a Washington license.

All the doctors with UW Medicine have been trained, or are being trained on how to care for patients via telemedicine. The number of people using the service has increased tenfold since public health officials urged patients to not visit emergency rooms or visit clinics for minor issues, said Dr. John Scott, director of digital health at UW Medicine.

Some hospitals are creating wards for COVID-19 patients. EvergreenHealth, in Kirkland, converted its 8th floor for the use of these patients.

King County officials last week purchased a motel, which could allow patients to recover outside a clinical setting and free up beds.

“These are places for people to recover and convalesce who are not at grave medical risk, and therefore do not need to be in a hospital,” said Alex Fryer, spokesperson for King County Executive Dow Constantine.

Supply problems are ongoing, even after the federal government fulfilled a first shipment that included tens of thousands of N95 respirator masks, surgical masks and disposable gowns from a federal stockpile.

Piazza said the nursing association continues to receive reports that members at area hospitals are being asked to reuse or share personal protective equipment, wear only one mask a shift or conserve masks for use exclusively with COVID-19 confirmed patients.

“We need to address the safety of frontline caregivers,” Piazza said.

State officials placed a second order for supplies last weekend.

Casey Katims, director of federal affairs for Inslee, said three trucks of medical supplies from the federal stockpile arrived Thursday morning, including 129,380 N-95 respirators; 308,206 surgical masks; 58,688 face shields; 47,850 surgical gowns; and 170,376 glove pairs.

If the measures taken now aren’t enough, state officials have contingency plans they’ve been working on “for a while now,” said Lofy, the state health officer.

“The next step is to start thinking about alternate care systems or alternate care facilities. These are facilities that could potentially be used outside the clinic or the health care system walls.”

 

 

 

 

Confronting a national emergency over coronavirus

https://mailchi.mp/325cd862d7a7/the-weekly-gist-march-13-2020?e=d1e747d2d8

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President Trump declared a national emergency today, in response to the growing spread of coronavirus across the country. The administration had come under sharp criticism for its sluggish response to the coronavirus crisis, in particular the widespread shortage of tests. Dr. Antony Fauci, director of the National Institute of Health’s infectious disease branch, told Congress on Thursday that the government’s response on testing was “not really geared to what we need right now…That’s a failing. Let’s admit it.”

In response, the administration today announced a series of emergency steps to increase testing capacity, turning to private labs to support the effort. The emergency status frees up $50B in federal emergency funding. Trump also announced that the Health and Human Services (HHS) Secretary will be able to waive regulations around telemedicine licensing, critical access hospital bed requirements and length of stay, and other measures to provide hospitals with added flexibility. House Speaker Nancy Pelosi and Treasury Secretary Steven Mnuchin have negotiated a sweeping aid package that would strengthen safety net programs, and offer sick leave for American workers affected by the virus.

Meanwhile, the American economy likely entered a recession, as consumers continued to pull back on spending on airline travel, entertainment, and other discretionary areas, while financial markets experienced the worst one-day drop in more than 30 years. Many school districts and universities shut down and announced plans to convert to online instruction for the foreseeable future. Employers imposed broad travel restrictions on their employees, moved to teleworking where possible, and even began to lay off workers as demand for services cratered. Shoppers stocked up on staples, cleaning supplies, and (inexplicably) toilet paper, as shelves ran bare in many stores.

Epidemiologists and disease experts urged broad adoption of “social distancing”, restricting large gatherings and reducing the ability of the virus to spread person-to-person. The objective: “flattening the curve” of transmission, so that the healthcare delivery system does not become overwhelmed as the virus spreads exponentially.

 

 

 

 

The Velvet Rope Economy: How Inequality Became Big Business

https://mailchi.mp/9e118141a707/the-weekly-gist-march-6-2020?e=d1e747d2d8

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FROM THE GIST BOOKSHELF

Feed your head—read this.

Income inequality has become a central topic in our national political debate in the wake of the financial crisis. The gap between the “haves” and “have nots” has grown steadily, and addressing that gap has become a key priority for a new generation of politicians, economists, and policymakers. But inequality has also become a lucrative business opportunity in many parts of the economy, a phenomenon that New York Times economics reporter Nelson Schwartz entertainingly (and unsettlingly) describes in his new book, The Velvet Rope Economy: How Inequality Became Big Business.

Based on a series of Times articles by Schwartz from the past several years, the book describes life on both sides of the “velvet rope”: how services have become faster, better, and higher quality for those with the ability to pay extra, and how the rest of us are getting left behind. He describes how the familiar amusement-park “Fast Pass” approach has pervaded other parts of our lives, from school sports to social services to travel, and yes, to healthcare.

Across the economy, businesses increasingly cater to the top tier of customers, providing privileged access, concierge services, and special perks. As Schwartz describes it, “This pattern—a Versailles-like world of pampering for a privileged few on one side of the velvet rope, a mad scramble for basic service for everyone else—is being repeated in one sphere of American society after another.”

It’s a phenomenon we see in healthcare every day, as rural hospitals are shuttered, access to care is restricted for Medicaid patients, and wait times for new primary care appointments soar to six weeks or more, while concierge physician practices and cash-based, on-demand services proliferate. Most troubling, in Schwartz’s view: this intentional, class-based separation causes those on one side of the “velvet rope” to misunderstand, and even denigrate, those on the other.

That aptly describes our current political dynamic—Schwartz provides a useful (and highly readable) window into how businesses seek to profit from that division. Worth a read.

 

 

Trump Medicaid proposal sparks bipartisan warnings

https://thehill.com/policy/healthcare/483564-trump-medicaid-proposal-sparks-bipartisan-warnings?utm_source=The+Fiscal+Times&utm_campaign=59b997dc59-EMAIL_CAMPAIGN_2020_02_19_10_03&utm_medium=email&utm_term=0_714147a9cf-59b997dc59-390702969

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Republicans and Democrats alike are warning that a recent proposal from the Trump administration could lead to billions of dollars in cuts to Medicaid, forcing states to eliminate benefits, reduce enrollment or cut payments to health providers.

In a rare sign of unity, hospitals, insurers, patient advocates and members of both political parties are on the same page in their opposition to the Trump administration’s plan, and most have urged the administration to withdraw a proposal they say would “cripple” Medicaid, the federal-state partnership that provides health care for the poor.

The proposal hasn’t received as much attention as the administration’s other efforts to reform Medicaid, such as implementing work requirements, but it could have the most damaging effect because of how far-reaching it is, experts argue.

“This is high stakes,” said Matt Salo, executive director of the National Association of Medicaid Directors, whose board urged the administration to completely withdraw the proposal.

Trump allies have also voiced their concerns.

“The Medicaid fiscal accountability rule is a concern to my governor, and the stakeholders are worried the rule as proposed could lead to hospital closures, problems with access to care and threaten the safety net,” Sen. John Cornyn (R-Texas) told Department of Health and Human Services Secretary Alex Azar last week during a hearing on the agency’s fiscal 2021 budget request.

Sen. Mark Warner (D-Va.) warned during the same hearing that the proposal could “dramatically affect Medicaid eligibility” and “wreak havoc on budgets in red states and blue states all across the country.”

The proposal would overhaul the complex payment arrangements states use to raise money for their Medicaid programs — funding that is then matched by the federal government.

The administration argues some states use questionable methods of raising funds so they can leverage more money from Washington. One approach used by states consists of taxing providers who stand to benefit from more Medicaid funds flowing into the state.

But governors and state Medicaid directors argue those long-standing arrangements are both legal and necessary as states look for ways to keep up with escalating health care costs.

The proposal would allow the Centers for Medicare and Medicaid Services (CMS) to limit the extra payments from states to providers serving high numbers of uninsured patients or Medicaid patients. Opponents say such changes could result in providers deciding not to accept Medicaid patients.

Dozens of states wrote public comments to CMS Administrator Seema Verma, urging her to withdraw the proposal, including conservative states that are typically supportive of her work.

“If the rule is finalized as proposed, it will immediately disrupt the Medicaid program in Alabama and we believe across the country,” wrote Stephanie McGee Azar, commissioner of the Alabama Medicaid Agency, who is not related to Alex Azar. She added that it would have “unintended consequences that will affect access to care in Alabama to our most vulnerable populations.”

Florida Gov. Ron DeSantis’s (R) administration warned the effect of the proposal would be “immediate and crippling.”

Meanwhile, a letter signed by state Medicaid officials in Michigan, Missouri, New York, Oregon, Pennsylvania, South Carolina, Tennessee, Illinois, Louisiana, Colorado, Pennsylvania and Washington argued the proposal would likely “force states to cut Medicaid eligibility, benefits and/or provider payments, which would have the effect of decreasing low-income individuals’ access to important health care services.”

The public comment period closed Jan. 31. CMS now needs to go through the 4,000 comments before deciding whether to finalize the rule.

Verma and her supporters argue the proposal is not intended to cut Medicaid but instead aims to improve transparency and accountability in the $600 billion a year program.

“It’s not surprising providers and the states are objecting when they are getting federal money for free,” argued Brian Blase, who previously served on President Trump’s National Economic Council, where he worked on health care issues. “They don’t want transparency and they don’t want their financing gimmicks checked.”

Blase predicted the rule, if implemented as proposed, would reduce Medicaid spending by a “very small amount.”

Verma also pushed back on opponents, criticizing a study commissioned by the American Hospital Association that estimated the rule could reduce Medicaid funding by as much as $49 billion annually.

“This proposed rule is not intended to reduce Medicaid payments, and alarmist estimates that this rule, if finalized, will suddenly remove billions of dollars from the program and threaten beneficiary access are overblown and without credibility,” she wrote in a blog post last week.

Some experts disagree with her, pointing to other actions the administration has taken on Medicaid, including work requirements.

“I think one should view this rule not in isolation, but in combination with the broader agenda of this administration on Medicaid,” said Edwin Park, a research professor at Georgetown University McCourt School of Public Policy. “Their ultimate agenda is about cutting the Medicaid program, changing the Medicaid program as it currently stands.”

State officials have complained that they were not asked for their input before the proposal was released, nor did CMS conduct a regulatory analysis of potential effects.

A nonpartisan agency that advises Congress on Medicaid policy wrote to Alex Azar advising he not implement the rule because CMS has not fully assessed the possible effects.

“The Commission is concerned that the proposed changes could reduce payments to providers in ways that could jeopardize access to care for Medicaid enrollees,” the advisory group wrote.

For example, Maine’s Department of Health and Human Services has planned to make $86 million in supplemental payments to hospitals in fiscal 2020, which began July 1.

The rule “would require significant changes to MaineCare and could force the State to cut back on eligibility or services,” Jeanne Lambrew wrote in the department’s public comment.

The administration hasn’t given any signals that it plans to back down from the proposal, despite considerable pushback from stakeholders, states and bipartisan members of Congress.

“We will work with states to help them recreate their practices in ways that are in conformity with the statute and try to be fair and equitable in all our dealings with states,” Alex Azar told lawmakers last week on Capitol Hill.

 

 

 

 

Public Charge Rule Could Erode Enrollment in Insurance Coverage

Public Charge Rule Could Erode Enrollment in Insurance Coverage

Mother and baby at clinic with doctor. Baby is looking directly into the camera.

In a 5-4 vote reflecting the ideological split among the justices, the US Supreme Court on January 27 decided to allow the Trump administration to commence enforcement (PDF) of its “public charge” rule nationwide. Only Illinois, where a statewide injunction is currently in effect, will not begin enforcing the rule. The regulation was slated to take effect last October, but federal judges in California, Illinois, Maryland, New York, and Washington blocked its implementation after states and immigrant rights groups challenged its legality. Federal appeals courts later lifted all but New York’s nationwide injunction and Illinois’ statewide injunction. The Supreme Court has now “stayed,” or put on hold, New York’s injunction, allowing the rule to take effect while the litigation continues.Essential Coverage

The US Citizenship and Immigration Services agency said the new rule will become effective February 24.

The public charge rule sparked controversy because it “would expand the government’s ability to refuse green cards or visas for legal immigrants determined to be a ‘public charge,’ or dependent on public assistance,” Susannah Luthi explained in Politico. “Those using or likely to use Medicaid, food stamps, and other safety-net programs would face greater scrutiny from immigration officials.”

Experts have warned of a “chilling effect” among immigrant communities, meaning that even those who are not subject to the public charge rule could disenroll or avoid public benefits out of fear. The Institute for Community Health estimated that 195,000 to 455,000 California children in need of medical attention could leave Medi-Cal if the rule takes effect. Including adults, this estimate grows to between 317,000 and 741,000 Californians disenrolling from Medi-Cal, according to researchers from UCLA and UC Berkeley (PDF).

The chilling effect has been documented on a national scale. According to the Urban Institute, in 2018, the year when the Trump administration proposed expanding the public charge rule, about 14% of adults in immigrant families reported that fear prompted them or a family member not to apply for a public benefit program or to disenroll from one. Of the adults who experienced chilling effects, 42% said they or their family members did not participate in Medicaid or the Children’s Health Insurance Program.

Soon after the rule was finalized last year, Eisner Health, a community clinic in Los Angeles, started getting phone calls from patients enrolled in Medi-Cal and CalFresh who wanted to end their families’ coverage, Claudia Boyd-Barrett reported in California Health Report. Many of those patients were not yet permanent residents or were members of mixed immigration status families who feared being penalized for using public benefits.

New Rule Doesn’t Apply to Many Immigrants

It is important to note that many immigrants are not subject to the new public charge rule. “It is urgent that all of us working with immigrant communities — via government, legal aid, health care, and more — have accurate and accessible information for families,” Sandra R. Hernández, president and CEO of CHCF, wrote on Twitter.

Mark Ghaly, California Health and Human Services Agency secretary, released a statement emphasizing that immigrant families should learn their rights. “You can find a list of nonprofit organizations providing free legal immigration services on the California Department of Social Services (CDSS) website, here,” Ghaly said.

CDSS offers a list of legal services providers across California who can assist with public charge questions. Protecting Immigrant Families (a partnership of the National Immigration Law Center and The Center for Law and Social Policy) also has resources on the public charge rule.

Following the Supreme Court’s order to stay the nationwide injunction, California Attorney General Xavier Becerra reiterated his commitment to fighting the rule. “We are a nation of immigrants, so we will lean forward in the face of heartless attacks on working families,” Becerra said in a statement. “Together, we’ll continue our fight to stand up for the right of each and every person who calls the United States their home.”

The legal challenges to the public charge rule will continue to move forward in courts around the nation — including in California — the New York Times’s Adam Liptak reported.

Medicaid Block Grants Could Reduce Access for Many

The Trump administration has announced its plan to let states volunteer to convert a portion of their Medicaid funding into block grants. The program, which has been branded a “Healthy Adult Opportunity,” represents a radical change in financing for Medicaid. Medicaid programs, which are operated by states with significant federal funding and oversight, constitute the nation’s health insurance program for Americans with low incomes. Covering over 75 million people, or one in five Americans, Medicaid programs provide services to 83% of children from low-income families, 48% of children with special health care needs, and 45% of nonelderly adults with disabilities.

On January 30, the administrator of the US Centers for Medicare & Medicaid Services, Seema Verma, sent to state Medicaid directors a letter (PDF) about the new block grant program. Verma gave states “the possibility of trading away an entitlement program that expands and contracts depending on how many poor people need the government health coverage,” Amy Goldstein wrote in the Washington Post. “In exchange, for able-bodied adults in the program, states could apply to receive a fixed federal payment and freedom from many of the program’s rules.”

Additionally, participating states would be allowed to limit the health benefits and drugs offered by their Medicaid programs, Rachel Roubein and Dan Diamond reported for Politico. According to one official, patients with behavioral health needs or HIV would be protected under the new plan.

Criticism from Medicaid advocates was swift. Twenty-seven patient and consumer groups, including the American Lung Association, American Cancer Society, and National Alliance on Mental Illness, issued a statement expressing strong opposition to the new guidance. “Block grants and per capita caps will reduce access to quality and affordable health care for patients with serious and chronic health conditions and are therefore unacceptable to our organizations,” they wrote.

“Worst Medicaid Idea Ever”

Frederick Isasi, executive director of Families USA, said in a statement, “Having spent many years working with governors and Medicaid programs, block grants are possibly the worst Medicaid idea ever presented to states by a federal administration. They would allow the federal government to off-load shared Medicaid responsibility at the expense of deep cuts to state budgets, vital programs supported by states, and the people who rely on those programs.”

Joan Alker, executive director and a cofounder of Georgetown University’s Center for Children and Families, warned in a statement that “if states accept a fixed cap on federal funding to meet their health care needs, they may be able to get by in the short term, but they put the health of their citizens and future state budgets at serious risk down the road.”

The block grant program is unlikely to affect California, which has invested heavily in expanding Medi-Cal access and is not expected to apply to participate.

Nonetheless, the block grant proposal shows that the Trump administration continues to prioritize changes that weaken the foundation of the nation’s health care safety net and could dramatically reduce health coverage for millions of Americans with low incomes.