The Biden administration is quietly engineering a series of expansions to Medicaid that may bolster protections for millions of low-income Americans and bring more people into the program.
Biden’s efforts — which have been largely overshadowed by other economic and health initiatives — represent an abrupt reversal of the Trump administration’s moves to scale back the safety-net program.
The changes could further boost Medicaid enrollment — which the pandemic has already pushed to a record 80.5 million. Some of the expansion is funded by the COVID-19 relief bill that passed in March, including coverage for new mothers.
Others who could also gain coverage under Biden are inmates and undocumented immigrants. At the same time, the administration is opening the door to new Medicaid-funded services such as food and housing that the government insurance plan hasn’t traditionally offered.
“There is a paradigm change underway,” said Jennifer Langer Jacobs, Medicaid director in New Jersey, one of a growing number of states trying to expand home-based Medicaid services to keep enrollees out of nursing homes and other institutions.
“We’ve had discussions at the federal level in the last 90 days that are completely different from where we’ve ever been before,” Langer Jacobs said.
Taken together, the Medicaid moves represent some of the most substantive shifts in federal health policy undertaken by the new administration.
“They are taking very bold action,” said Rutgers University political scientist Frank Thompson, an expert on Medicaid history, noting in particular the administration’s swift reversal of Trump policies. “There really isn’t a precedent.”
The Biden administration seems unlikely to achieve what remains the holy grail for Medicaid advocates: getting 12 holdout states, including Texas and Florida, to expand Medicaid coverage to low-income working-age adults through the Affordable Care Act.
And while some of the recent expansions – including for new mothers — were funded by close to $20 billion in new Medicaid funding in the COVID relief bill Biden signed in March, much of that new money will stop in a few years unless Congress appropriates additional money.
The White House strategy has risks. Medicaid, which swelled after enactment of the 2010 health law, has expanded further during the economic downturn caused by the pandemic, pushing enrollment to a record 80.5 million, including those served by the related Children’s Health Insurance Program. That’s up from 70 million before the COVID crisis began.
The programs now cost taxpayers more than $600 billion a year. And although the federal government will cover most of the cost of the Biden-backed expansions, surging Medicaid spending is a growing burden on state budgets.
The costs of expansion are a frequent target of conservative critics, including Trump officials like Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services, who frequently argued for enrollment restrictions and derided Medicaid as low-quality coverage.
But even less partisan experts warn that Medicaid, which was created to provide medical care to low-income Americans, can’t make up for all the inadequacies in government housing, food and education programs.
“Focusing on the social drivers of health … is critically important in improving the health and well-being of Medicaid beneficiaries. But that doesn’t mean that Medicaid can or should be responsible for paying for all of those services,” said Matt Salo, head of the National Association of Medicaid Directors, noting that the program’s financing “is simply not capable of sustaining those investments.”
Restoring federal support
However, after four years of Trump administration efforts to scale back coverage, Biden and his appointees appear intent on not only restoring federal support for Medicaid, but also boosting the program’s reach.
“I think what we learned during the repeal-and-replace debate is just how much people in this country care about the Medicaid program and how it’s a lifeline to millions,” Biden’s new Medicare and Medicaid administrator, Chiquita Brooks-LaSure, told KHN, calling the program a “backbone to our country.“
The Biden administration has already withdrawn permission the Trump administration had granted Arkansas and New Hampshire to place work requirements on some Medicaid enrollees.
In April, Biden blocked a multibillion-dollar Trump administration initiative to prop up Texas hospitals that care for uninsured patients, a policy that many critics said effectively discouraged Texas from expanding Medicaid coverage through the Affordable Care Act, often called Obamacare. Texas has the highest uninsured rate in the nation.
The moves have drawn criticism from Republicans, some of whom accuse the new administration of trampling states’ rights to run their Medicaid programs as they choose.
“Biden is reasserting a larger federal role and not deferring to states,” said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.
But Biden’s early initiatives have been widely hailed by patient advocates, public health experts and state officials in many blue states.
“It’s a breath of fresh air,” said Kim Bimestefer, head of Colorado’s Department of Health Care Policy and Financing.
Chuck Ingoglia, head of the National Council for Mental Wellbeing, said: “To be in an environment where people are talking about expanding health care access has made an enormous difference.”
Mounting evidence shows that expanded Medicaid coverage improves enrollees’ health, as surveys and mortality data in recent years have identified greater health improvements in states that expanded Medicaid through the 2010 health law versus states that did not.
In addition to removing Medicaid restrictions imposed by Trump administration officials, the Biden administration has backed a series of expansions to broaden eligibility and add services enrollees can receive.
Biden supported a provision in the COVID relief bill that gives states the option to extend Medicaid to new mothers for up to a year after they give birth. Many experts say such coverage could help reduce the U.S. maternal mortality rate, which is far higher than rates in other wealthy nations.
Several states, including Illinois and New Jersey, had sought permission from the Trump administration for such expanded coverage, but their requests languished.
The COVID relief bill — which passed without Republican support — also provides additional Medicaid money to states to set up mobile crisis services for people facing mental health or substance use emergencies, further broadening Medicaid’s reach.
And states will get billions more to expand so-called home and community-based services such as help with cooking, bathing and other basic activities that can prevent Medicaid enrollees from having to be admitted to expensive nursing homes or other institutions.
Perhaps the most far-reaching Medicaid expansions being considered by the Biden administration would push the government health plan into covering services not traditionally considered health care, such as housing.
This reflects an emerging consensus among health policy experts that investments in some non-medical services can ultimately save Medicaid money by keeping patients out of the hospital.
In recent years, Medicaid officials in red and blue states — including Arizona, California, Illinois, Maryland and Washington — have begun exploring ways to provide rental assistance to select Medicaid enrollees to prevent medical complications linked to homelessness.
The Trump administration took steps to support similar efforts, clearing Medicare Advantage health plans to offer some enrollees non-medical benefits such as food, housing aid and assistance with utilities.
But state officials across the country said the new administration has signaled more support for both expanding current home-based services and adding new ones.
That has made a big difference, said Kate McEvoy, who directs Connecticut’s Medicaid program. “There was a lot of discussion in the Trump administration,” she said, “but not the capital to do it.”
Other states are looking to the new administration to back efforts to expand Medicaid to inmates with mental health conditions and drug addiction so they can connect more easily to treatment once released.
Kentucky health secretary Eric Friedlander said he is hopeful federal officials will sign off on his state’s initiative.
Still other states, such as California, say they are getting a more receptive audience in Washington for proposals to expand coverage to immigrants who are in the country without authorization, a step public health experts say can help improve community health and slow the spread of communicable diseases.
“Covering all Californians is critical to our mission,” said Jacey Cooper, director of California’s Medicaid program, known as Medi-Cal. “We really feel like the new administration is helping us ensure that everyone has access.”
The Trump administration moved to restrict even authorized immigrants’ access to the health care safety net, including the “public charge” rule that allowed immigration authorities to deny green cards to applicants if they used public programs such as Medicaid.In March, Biden abandoned that rule.
Medicare Advantage (MA) focused companies, like Oak Street Health (14x revenues), Cano Health (11x revenues), and Iora Health (announced sale to One Medical at 7x revenues), reflect valuation multiples that appear irrational to many market observers. Multiples may be exuberant, but they are not necessarily irrational.
One reason for high valuations across the healthcare sector is the large pools of capital from institutional public investors, retail investors and private equity that are seeking returns higher than the low single digit bond yields currently available. Private equity alone has hundreds of billions in investable funds seeking opportunities in healthcare. As a result of this abundance of capital chasing deals, there is a premium attached to the scarcity of available companies with proven business models and strong growth prospects.
Valuations of companies that rely on Medicare and Medicaid reimbursement have traditionally been discounted for the risk associated with a change in government reimbursement policy. This “bop the mole” risk reflects the market’s assessment that when a particular healthcare sector becomes “too profitable,” the risk increases that CMS will adjust policy and reimbursement rates in that sector to drive down profitability.
However, there appears to be consensus among both political parties that MA is the right policy to help manage the rise in overall Medicare costs and, thus, incentives for MA growth can be expected to continue. This factor combined with strong demographic growth in the overall senior population means investors apply premiums to companies in the MA space compared to traditional providers.
Large pools of available capital, scarcity value, lower perceived sector risk and overall growth in the senior population are all factors that drive higher valuations for the MA disrupters.However, these factors pale in comparison the underlying economic driver for these companies. Taking full risk for MA enrollees and dramatically reducing hospital utilization, while improving health status, is core to their business model. These companies target and often achieve reduced hospital utilization by 30% or more for their assigned MA enrollees.
In 2019, the average Medicare days per 1,000 in the U.S. was 1,190. With about $14,700 per Medicare discharge and a 4.5 ALOS, the average cost per Medicare day is approximately $3,200. At the U.S. average 1,190 Medicare hospital days per thousand, if MA hospital utilization is decreased by 25%, the net hospital revenue per 1,000 MA
enrollees is reduced by about $960,000. If one of the MA disrupters has, for example, 50,000 MA lives in a market, the decrease in hospital revenues for that MA population would be about $48 million. This does not include the associated physician fees and other costs in the care continuum. That same $48 million + in the coffers of the risk-taking MA disrupters allows them deliver comprehensive array of supportive services including addressing social determinants of health. These services then further reduce utilization and improves overall health status, creating a virtuous circle. This is very profitable.
MA is only the beginning. When successful MA businesses expand beyond MA, and they will, disruption across the healthcare economy will be profound and painful for the incumbents. The market is rationally exuberant about that prospect.
The country is reopening. What does the future hold?
The story of the American pandemic has unfolded in three chapters.The first began last January, when the coronavirus emerged and the world was plunged into uncertainty about how covid-19 could be treated, how the virus spread, and when it might be defeated. The second started on the morning of November 9, 2020, when Pfizer-BioNTech announced the extraordinary efficacy of its vaccine. Those results made clear that this pandemic would end not through infection but vaccination. Our goals shifted from merely slowing the spread to beginning immunization as quickly as possible. In America, much of the past half year has been devoted to administering vaccines and gathering evidence on how well they work in the real world.
Earlier this month, the Centers for Disease Control and Prevention ushered in the American pandemic’s third chapter. The agency announced that vaccinated people could go without masks or social distancing indoors and outside, in crowds large and small. It carved out a few exceptions—for hospitals, public transportation, and the like—and noted that people still needed to obey federal and local laws. But the broad message was that vaccinated Americans could resume their pre-pandemic lives. The C.D.C. is an agency known for caution, and its new guidance shocked many public-health experts; just two weeks earlier, it had issued far more restrictive recommendations. During the same period, a survey of nearly six hundred epidemiologists found that more than three-quarters of them believed that indoor mask-wearing might remain necessary for another year or more. Still, immediately after the announcement, a number of states lifted their mask mandates. Others will surely follow, as the pressure to return to normal grows. America is now moving swiftly toward reopening.
Despite the C.D.C.’s early stumbles on communication, masks, and tests, it remains perhaps the world’s preëminent public-health agency. Its recommendations carry unparalleled scientific force in the U.S. and beyond. Ultimately, the C.D.C.’s decision reflects real shifts in the weight of the evidence on several fundamental epidemiological questions: Are the vaccines as effective as they were in the trials? Can they protect us against the coronavirus variants? And do they prevent not just illness but transmission? The answers to these questions give us good reason to think that the pandemic’s newest chapter will be its last. Read The New Yorker’s complete news coverage and analysis of the coronavirus pandemic.
On the first question, the nationwide rollout of covid-19 vaccines has proved, beyond any doubt, that they are astonishingly effective at preventing serious illness, even for the most vulnerable people. So-called breakthrough infections, in which the virus weaves its way around some of an individual’s immune system, do occur. But such infections are extremely rare, and—because a person almost always has some effective antibodies and other immune-system defenses—they usually cause mild or no symptoms. In one study, the C.D.C. examined post-vaccination infections among nearly fifteen thousand nursing-home residents and staff members, and discovered only two covid-19 hospitalizations and one death. Another study, involving half a million health-care workers from around the country, found that getting two shots reduced the risk of a symptomatic infection by ninety-four per cent. Moving forward, we should expect to continue seeing breakthrough infections from time to time—but, for the most part, we shouldn’t worry about them. (At the same time, the covid vaccines have proved exceptionally safe. Few dangerous side effects have been linked to the vaccines from Pfizer-BioNTech or Moderna, and the over-all risk of concerning blood clots after receiving Johnson & Johnson’s vaccine is rare—as of last week, when more than nine million doses had been administered, there were thirty confirmed cases.)
The most striking vaccine-efficacy statistic draws on data shared by state governments. Around a hundred and thirty million Americans are fully vaccinated, and the C.D.C. has said that it has received reports of fewer than fourteen hundredcovid-19 hospitalizations and three hundred deaths among them. This means that, after vaccination, one’s chances of dying of covid-19 are currently about two in a million, with the likelihood of being hospitalized only slightly higher. Statistics reported by hospitals tend to be accurate; still, even if state governments have missed a few cases here and there, the results are staggeringly good. “The evidence on vaccines just keeps getting better and better,” Robert Wachter, a physician and the chair of medicine at the University of California, San Francisco, told me. “When the trial results first came out, I thought, They can’t actually be this good. The real world is always messier than the trials. What we’ve learned since then is that the vaccines are probably even more spectacular than we initially believed.”
The answer to the second question—whether the vaccines work against the major coronavirus variants—is also now clear. Earlier this month, a study conducted in Qatar, where the B.1.1.7 and B.1.351 variants predominate, found that the Pfizer-BioNTech vaccine was ninety-seven per cent effective at preventing severe disease. Vaccines from Moderna and Johnson & Johnson also appear to be highly effective against the variants; in fact, these vaccines are already successfully fighting them here in the United States. The B.1.1.7 variant, which is vastly more contagious than the original virus and caused a devastating surge in the U.K. this past winter, now accounts for three-quarters of new U.S. cases—and yet, largely thanks to vaccination, daily infections in this country have fallen by nearly ninety per cent since their peak in January, and are now lower than at any point in the past eight months. The existence of more contagious variants isn’t a reason to doubt the vaccines but to vaccinate people as quickly as possible.
As for the final question—whether vaccinated people can spread the virus to others, especially unvaccinated people, including children—the evidence is similarly encouraging. Because vaccinated people are unlikely to contract the virus, the vast majority won’t be passing it on. And even the small number of vaccinated people who experience breakthrough infections have much less of the virus circulating in their bodies, and may be less infectious. Real-world data from Israel, which has mounted one of the world’s fastest and most effective vaccination campaigns, is instructive. The country’s progress in immunizing its adults has been linked to significant declines in infections among unvaccinated people; according to one preliminary estimate, each twenty-percentage-point increase in adult vaccination rates reduces infections for unvaccinated children by half. When vaccinated people remove their masks, they pose little threat to others, and they face little peril themselves.
The shift toward reopening is not without risk. The first issue is timing. Less than half of Americans have received even one shot of a covid-19 vaccine, and only around four in ten have been fully vaccinated. This means that the majority of the country remains susceptible to infection and disease. Meanwhile, the pace of vaccinations has slowed: in April, the U.S. was routinely vaccinating about three million people per day, but the daily average is now nearly two million. It’s unclear whether the new guidance will encourage or deter unvaccinated Americans from getting immunized. In a recent survey, unvaccinated Republicans said that they would be nearly twenty per cent more likely to get the shots if it meant that they wouldn’t have to wear a mask anymore. We’ll now find out how they really feel.
Vaccine hesitancy is only part of the picture. Some thirty million Americans—a group larger than anti-vaxxers or the vaccine-hesitant—say that they want to get immunized but haven’t yet done so. Some face language barriers, or fear immigration problems; others have difficulty navigating the health system, or can’t take time off from work. Many of the willing-but-unvaccinated are working-class Americans; four in five don’t have a college degree. The Biden Administration has sent billions of dollars to health centers serving low-income populations, offered tax credits to businesses that provide paid time off for employees to get immunized, and helped assemble thousands of volunteers—known as the covid-19 Community Corps—to assist with vaccine outreach to underserved populations. States, too, are trying to reduce barriers to vaccination, and offering incentives—including payments in Maryland, a lottery in Ohio, and a “Shot and a Beer” program in New Jersey—for residents who remain on the fence. There are, in short, real efforts under way to sway the vaccine-hesitant and make vaccines more accessible.
Still, the new C.D.C. guidance makes these efforts even more urgent. Until now, unvaccinated people have been shielded from high levels of viral exposure by government mandates and social norms that have kept their friends, neighbors, and colleagues masked and distanced, to varying degrees. But, in the coming weeks, those protections will likely erode. For unvaccinated Americans, this could be the most dangerous moment in the pandemic. In most contexts, there is no reliable mechanism for verifying who has and hasn’t been vaccinated. Inevitably, against the C.D.C.’s advice, many unvaccinated people will resume normal life, too, threatening their own health and that of others. When asked how businesses are to know which customers can enter unmasked, Anthony Fauci, the nation’s top infectious-disease expert, told CNN, “They will not be able to know. You’re going to be depending on people being honest enough to say whether they were vaccinated or not.”
“Unvaccinated people are now going to have much higher levels of exposure,” Wachter told me. “That’s especially true in places with lots of community spread and in places where more contagious variants are circulating.” Wachter suggested that the C.D.C. could be making an epidemiological bet. The move “will cause some additional covid cases that otherwise would not have occurred,” he said—but, “if it leads to even a small uptick in vaccination, it will save lives in aggregate.”
Since the start of the pandemic’s second chapter, public-health officials have been working to prevent a catastrophic collision between the ship of reopening and the iceberg of the unvaccinated. By slowing the speed of the ship or shrinking the size of the iceberg, we have sought to reduce the force of the collision. But barring a hundred-per-cent vaccination rate, or something close to it—an outcome that the U.S. was never likely to achieve—a crash of some sort has been inevitable.India’s collision has been titanic—it reopened with a population of more than a billion, even though hardly anyone was vaccinated. In the U.S., the situation is different. Our iceberg has been melting, and we’ve been approaching it slowly. Now we’re taking off the brakes.
The C.D.C. issues guidance, not laws; there are several quantitative measures that states, counties, cities, companies, and individuals can consult in pacing their reopening and squaring the agency’s broad recommendations with local realities. A community’s immunization rate is perhaps the most obvious statistic to track. Experts have argued for meeting a seventy-per-cent immunity threshold before relaxing masking and distancing requirements. No states have got there yet, although some, such as Vermont and Maine, are well on their way. The Biden Administration has said that it hopes to hit the seventy-per-cent target for first shots by the Fourth of July.
Because the vaccines prevent almost all cases of severe covid-19, the number of covid-19 hospitalizations is another good metric to watch. “With vaccines, cases become uncoupled from severe disease,” Monica Gandhi, an infectious-disease doctor at the University of California, San Francisco, who has studied asymptomatic coronavirus transmission, told me. Gandhi was among the first researchers to show that masks protect not just others but wearers, too; when we spoke, before the C.D.C.’s announcement, she said that, in her view, most precautions could end when half of Americans had received their first shot and covid-19 hospitalizations had fallen below sixteen thousand nationally, or about five per hundred thousand people. (At the peak of most flu seasons, the U.S. records five to ten influenza hospitalizations per hundred thousand.) Hospitalizations appear to be falling, unevenly, across the country. However, there are currently thirty thousand Americans hospitalized with covid-19—roughly a quarter of the January peak, but still about twice Gandhi’s threshold.
Herd immunity offers a third benchmark for reopening. The idea is that, once about eighty per cent of the population has been vaccinated or infected, the virus will struggle to spread. Recently, some experts have argued that we might never get to herd immunity because of variants, vaccine hesitancy, and the fact that children under twelve, who make up some fifteen per cent of the U.S. population, are unlikely to be immunized for some time. But the C.D.C.’s recommendation could change the equation. As states lift restrictions and unvaccinated people face higher levels of exposure, more of them are likely to get infected, pushing us closer to the herd immunity threshold. In all likelihood, the U.S. will be able to reach sixty-per-cent vaccination in the coming weeks; meanwhile, perhaps a third of Americans have already been infected. Even assuming significant overlap between the two groups, the combination of vaccination and infection is likely to make it harder for the virus to find new hosts. Marc Lipsitch, the director of Harvard’s Center for Communicable Disease Dynamics, emphasized that, because some parts of the country may reach herd immunity, or something close to it, before others—Connecticut’s current covid-19 immunization rate, for instance, is nearly twice Mississippi’s—unvaccinated adults will face different levels of risk depending on where they live. “There won’t be one national end,” Lipsitch told me. “We’re going to see a fundamental change in terms of what it means to live in this country, but there’s also going to be a lot of local variation.”
Covid-19 deaths give us another way of tracking the pandemic. Experts have argued that the U.S., with a population of three hundred and thirty-two million, should aim for fewer than a hundred coronavirus deaths daily—roughly the toll of a typical flu season. Right now, America is seeing about six hundred covid-19 deaths each day; according to the Institute for Health Metrics and Evaluation, which generates one of the country’s most widely cited pandemic models, that number will likely fall to about a hundred in August. “Things will look very good this summer,” Christopher Murray, the director of the I.H.M.E., told me. “A lot of people will think that we’re done, that it’s all over. But what happens in the fall is the tricky part.” Murray believes that a confluence of factors—the spread of variants, in-person schooling, meaningful numbers of still-unvaccinated people, and the seasonality of the virus—will produce a small winter spike, concentrated in communities with low vaccination rates. It won’t be the apocalyptic surge of New York City in the spring of 2020—or, more recently, those of India or Brazil—but, each week, several thousand unvaccinated Americans could die.
It’s possible, given all this, to imagine a plausible scenario for the conclusion of the American pandemic. The coronavirus disease toll continues to fall throughout the summer. States do away with mask mandates and capacity restrictions; people increasingly return to bars, spin classes, and airports, then to stadiums, movie theatres, and concerts. By midsummer, in communities with high vaccination rates, covid-19 starts to fade from view. In those places, even people who remain unvaccinated are protected, because so little of the virus circulates. But, in other parts of the country, low immunization rates combined with reopening allow the disease to register again. Hospitals aren’t overwhelmed—there’s no need to build new I.C.U.s or call in extra staff—but the collision between ship and iceberg is forceful, and each week thousands of people fall ill and hundreds die. Some victims are vaccine-hesitant; others were unable, for whatever reason, to get vaccinated. Still, perhaps unfairly, these outbreaks come with an aura of culpability: to people in safe parts of the country, the ill seem like smokers who get lung cancer.
In the fall, many unvaccinated children return to school. Scattered infections among them capture headlines, but serious illnesses are exceedingly rare; the overwhelming majority of children remain safe, and, with time, they, too, are immunized. The U.S. approaches something like herd immunity. Some people may still fall ill and die of covid-19—perhaps they are immunocompromised, elderly, or just unlucky—but, by and large, America has gained the upper hand. Meanwhile, in poor nations with few vaccines, the pandemic continues. As crisis wanes in one country, catastrophe ignites in another. Every so often, we learn of a new variant that’s thought to be more contagious, lethal, or vaccine-resistant than the rest; we rush to institute travel bans, only to learn that the variant, or a close cousin, is already circulating in the U.S. and has been largely subdued by the vaccines, as all previous variants have been. In the fall, Americans line up for covid booster shots alongside flu vaccines. The pandemic’s final chapter comes to a close not through official decree but with the gradual realization that covid-19 no longer dominates our lives.
Reopening a country after a pandemic isn’t like flipping a giant switch. It’s more like lighting a series of candles, illuminating one part, then another, until the whole place shines. Many states, counties, cities, and businesses will further loosen their restrictions; others will wait. Communities and individuals will approach the end of the crisis differently, as they’ve approached the rest of it. Some unvaccinated people have already been forgoing precautions; on the other hand, I’ve been vaccinated for months and, since the C.D.C. announcement, have yet to leave my mask behind—whether because of a lingering, irrational fear or simply to avoid dirty looks, I can’t say. Social norms take time to change, even when one of the world’s most respected public-health agencies is telling you to change them.
The pandemic has created not just chaos and suffering but uncertainty. It’s easy, therefore, to be doubtful about the fortunate position in which we seem to find ourselves now. As a physician, I spent the early months of the pandemic caring for covid-19 patients in New York City; they streamed into the hospital day after day, deathly ill. We raced to build covid wards, I.C.U.s, and hospice units. At the time, we had little to offer. There were no proven therapies, and certainly no vaccines. There were weeks when thousands of New Yorkers died, many of them alone in their final moments, while more people were dying across the world. I felt fear, anxiety, and sometimes despair. The scale of the damage—the lives lost, businesses shuttered, dreams shattered, children orphaned, seniors isolated—was crushing, and the path forward was both frightening and unknown.
As good news began to arrive, I greeted it with a blend of guarded skepticism and cautious optimism. First came evidence that outdoor transmission was unlikely. Then we learned that contaminated surfaces rarely spread disease; that some patients can breathe better simply by lying on their bellies; that P.P.E. works; that dexamethasone saves lives. We discovered that immunity lasts many months, perhaps years; that repeat infections are unlikely; and that variants present a surmountable challenge.
Now, study after study, in country after country, has shown that the vaccines are capable of transforming a lethal pathogen into a manageable threat. Examining and reëxamining the vaccine results, I’ve gone through stages, too—caution, hope, and, finally, clarity. We really are that close. The beginning of the end is here.
Throughout the COVID-19 pandemic, experts have been warning of the dangers of postponed health care services. In January, the American Cancer Society, the National Comprehensive Cancer Network, and 73 other organizations, including many major health care systems, issued a statement stressing the urgency of preventive care. “We urge people across the country to talk with their health care provider to resume regular primary care checkups, recommended cancer screening, and evidence-based cancer treatment (PDF) to lessen the negative impact the pandemic is having on identifying and treating people with cancer,” the groups said.
That was sound advice not everyone could follow, as ProPublica’s Duaa Eldeib reported last week in a tragic story about Teresa Ruvalcaba. The 48-year-old single mother of three worked for 22 years at a candy factory on Chicago’s West Side. During the pandemic, disaster struck. “For more than six months, the 48-year-old factory worker had tried to ignore the pain and inflammation in her chest. She was afraid of visiting a doctor during the pandemic, afraid of missing work, afraid of losing her job, her home, her ability to take care of her three children,” Eldeib reported.
“Even though her chest felt as if it was on fire, she kept working. She didn’t want to get COVID-19 at a doctor’s office or the emergency room, and she was so busy she didn’t have much time to think about her symptoms,” Eldeib wrote.
Ruvalcaba’s pandemic fears were typical of patients across the nation, surveys revealed. A 2020 CHCF poll of 2,249 California adults revealed that even when people wanted to see a doctor for an urgent health problem, one-third did not receive care. Nearly half of those surveyed didn’t receive care for their nonurgent health problems.
Nationally, more than one in three people delayed or skipped care because they were worried about exposure to Covid-19, or because their doctor limited services, according to an Urban Institute analysis of a September 2020 survey.
The toll of this disruption in care — the forgone cancer screening, the chest pain that isn’t reported — will devastate some patients and families. Ruvalcaba had to face a diagnosis with a terrible prognosis, inflammatory breast cancer. “If she would have come six months earlier, it could have been just surgery, chemo and done,” Ruvalcaba’s doctor told Eldeib. “Now she’s incurable.”
“Unfortunately, we know we’re going to see some tragedies related to the delays,” Wiley Fowler, an oncologist at Dignity Health in Sacramento, told Ibarra.
Consequences of Delayed Care
Public health messages early in the pandemic urged people to avoid public places, including doctor’s offices. In April, as Hayley Smith noted in a Los Angeles Times story, the US Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services “both published guidelines recommending the postponement of elective and nonurgent procedures, including ‘low-risk cancer’ screenings, amid the first wave of the pandemic.”
Patients and doctors listened. Appointments were canceled. “Nonurgent” procedures encompassing a wide array of treatments and operations, including cancer surgeries, were delayed.
Preventive cancer screenings dropped 94% over the first four months of 2020, Eldeib reported. The National Cancer Institute expects to see 10,000 preventable deaths over the next decade because of pandemic-related delays in diagnosis and treatment of breast and colorectal cancer. Screenings for these cancers, which account for about one in six cancer deaths, are routine features of preventive care.
I know I should get another check soon, but the anxiety of COVID feels like more of a priority than the anxiety of cervical cancer.
—Molly Codner, a Southern Californian who received an abnormal Pap smear last summer
In California, cancer deaths have remained roughly the same as prepandemic rates, but that stability is not expected to last. Based on the National Cancer Institute data, Ibarra calculates that an additional 1,200 Californians will die from breast and colon cancer. The National Cancer Institute estimate is conservative “because it only accounts for a six-month delay in care, and people are postponing care longer than that,” Ibarra reported.
Nationally, death rates from cancer are expected to increase in a year or two. Slow-growing cancers will remain treatable despite a delayed diagnosis, Norman Sharpless, MD, director of the National Cancer Institute, told Eldeib. Yet for conditions like Ruvalcaba’s inflammatory breast cancer, delayed care can be disastrous.
Women, People of Color Disproportionately Affected
For women across Southern California, appointments have been delayed, exams canceled, and screenings postponed during the pandemic, Smith reported in the Los Angeles Times. “Some are voluntarily opting out for fear of encountering the virus,” Smith wrote, “while others have had their appointments canceled by health care providers rerouting resources to COVID-19 patients.”
Before Pap smears became part of routine American health care, cervical cancer was one of the deadliest cancers for women. Today, as many as 93% of cervical cancer cases are preventable, according to the CDC, and screenings are a crucial component of preventive care. Yet during the first phase of California’s stay-at-home orders, cervical cancer screenings dropped 80% among the 1.5 million women in Kaiser Permanente’s regional network, Smith wrote.
The effects of the pandemic shutdown extended beyond delayed Pap smears. Women who spoke to Smith said that “mammograms, fertility treatments and even pain prevention procedures have been waylaid by the pandemic.”
Sometimes, obstacles other than the pandemic are continuing to interfere with access to care. One woman had an appointment delayed and then lost her job and her health insurance, Smith reported.
“Molly Codner, 30, has needed a checkup ever since she received an abnormal Pap smear last summer,” Smith wrote, “but like many Southern Californians, the trauma of the last year still weighs heavily on her mind: Nearly a dozen people she knows have had COVID-19.” Codner told Smith that “I know I should get another check soon, but the anxiety of COVID feels like more of a priority than the anxiety of cervical cancer.”
People who face disparities in treatment and care are most likely to be hard hit by pandemic delays. That includes Black people, who were already more likely to die from cancer than any other racial group. Cancer also is the leading cause of death among Latinx people. Breast cancer is the most common cancer diagnosis for Latinx women. Overall, more Americans die of heart disease.
Black adults are more likely than White or Latinx adults to delay or forgo care, according to researchers from the Urban Institute.
Telehealth Solved Access Issues for Some, Not All
Telehealth was a boon for patients during the pandemic year. Yet, as Ibarra notes, “there’s only so much that doctors and nurses can do through a screen.” Dental visits, mammograms, and annual wellness checks were also put on hold by the pandemic.
Latinx, Asian, and Black respondents did not use telehealth as often as White respondents. USC researchers attribute these differences to “disparities in income, education and access to any kind of health care.”
Researchers at the Urban Institute report similar findings: “Black and Latinx adults were more likely than White adults to report having wanted a telehealth visit but not receiving one since the pandemic began, and that difficulties getting a telehealth visit were also more common among adults who were in poorer health or had chronic health conditions.”
After controlling for socioeconomic factors and health status, patients with limited English were half as likely to use telehealth compared to fluent English-speaking patients, the Urban Institute said. “Much work remains to ensure all patients have equitable access to remote care during and after the pandemic,” the researchers wrote.
Whether telehealth is conducted by video or phone may be crucial to ensuring access to care. A study of telehealth use at Federally Qualified Health Centers in California in 2020 found that “more primary care visits among health centers in the study occurred via audio-only visits (49%) than in-person (48%) or via video (3%). Audio-only visits comprised more than 90% of all telemedicine visits.”
Public health efforts might need to focus on two goals at the same time as the US recovers from the pandemic: increasing vaccine uptake to keep COVID-19 in check and proactively managing the fallout from delayed care.
“As we focus on recovery, we have to ensure that we get vaccinated,” Efrain Talamantes, a primary care physician in East Los Angeles, told Ibarra. “But also that we have a concerted effort to manage the chronic diseases that haven’t received the attention required to avoid complications.”
Federally-subsidized childcare centers took care of an estimated 550,000 to 600,000 children while their mothers worked wartime jobs.
When the United States started recruiting women for World War II factory jobs, there was a reluctance to call stay-at-home mothers with young children into the workforce. That changed when the government realized it needed more wartime laborers in its factories. To allow more women to work, the government began subsidizing childcare for the first (and only) time in the nation’s history.
An estimated 550,000 to 600,000 children received care through these facilities, which cost parents around 50 to 75 cents per child, per day (in 2021, that’s less than $12). But like women’s employment in factories, the day care centers were always meant to be a temporary wartime measure. When the war ended, the government encouraged women to leave the factories and care for their children at home. Despite receiving letters and petitions urging the continuation of the childcare programs, the U.S. government stopped funding them in 1946.
Before World War II, organized “day care” didn’t really exist in the United States. The children of middle- and upper-class families might go to private nursery schools for a few hours a day, says Sonya Michel, a professor emerita of history, women’s studies and American studies at the University of Maryland-College Park and author of Children’s Interests/Mothers’ Rights: The Shaping of America’s Child Care Policy. (In German communities, five- and six-year-olds went to half-day Kindergartens.)
For children from poor families whose father had died or couldn’t work, there were day nurseries funded by charitable donations, Michel says. But there were no affordable all-day childcare centers for families in which both parents worked—a situation that was common for low-income families, particularly Black families, and less common for middle- and upper-class families.
The war temporarily changed that. In 1940, the United States passed the Defense Housing and Community Facilities and Services Act, known as the Lanham Act, which gave the Federal Works Agency the authority to fund the construction of houses, schools and other infrastructure for laborers in the growing defense industry. It was not specifically meant to fund childcare, but in late 1942, the government used it to fund temporary day care centers for the children of mothers working wartime jobs.
Communities had to apply for funding to set up day care centers; once they did, there was very little federal involvement. Local organizers structured childcare centers around a community’s needs. Many offered care at odd hours to accommodate the schedules of women who had to work early in the morning or late at night. They also provided up to three meals a day for children, with some offering prepared meals for mothers to take with them when they picked up their kids.
“The ones that we often hear about were the ‘model’ day nurseries that were set up at airplane factories [on the West coast],” says Michel. “Those were ones where the federal funding came very quickly, and some of the leading voices in the early childhood education movement…became quickly involved in setting [them] up,” she says.
For these centers, organizers enlisted architects to build attractive buildings that would cater to the needs of childcare, specifically. “There was a lot of publicity about those, but those were unusual. Most of the childcare centers were kind of makeshift. They were set up in church basements or garages.”
Though the quality of care varied by center, there hasn’t been much study of how this quality related to children’s race (in the Jim Crow South, where schools and recreational facilities were segregated, childcare centers were likely segregated too).At the same time, the United States was debuting subsidized childcare, it was also incarcerating Japanese American families in internment camps. So although these childcare facilities were groundbreaking, they didn’t serve all children.
Subsidized Childcare Ends When War Ends
When the World War II childcare centers first opened, many women were reluctant to hand their children over to them. According to Chris M. Herbst, a professor of public affairs at Arizona State University who has written about these programs in the Journal of Labor Economics, a lot of these women ended up having positive experiences.
“A couple of childcare programs in California surveyed the mothers of the kids in childcare as they were leaving childcare programs,” he says. “Although they were initially skeptical of this government-run childcare program and were worried about the developmental effects on their kids, the exit interviews revealed very, very high levels of parental satisfaction with the childcare programs.”
As the war ended in August 1945, the Federal Works Agency announced it would stop funding childcare as soon as possible. Parents responded by sending the agency 1,155 letters, 318 wires, 794 postcards and petitions with 3,647 signatures urging the government to keep them open. In response, the U.S. government provided additional funding for childcare through February 1946. After that, it was over.
Lobbying for national childcare gained momentum in the 1960s and ‘70s, a period when many of its advocates may have themselves gone to World War II day care as kids. In 1971, Congress passed the Comprehensive Child Development Act, which would have established nationally-funded, locally-administered childcare centers.
This was during the Cold War, a time when anti-childcare activists pointed to the fact that the Soviet Union funded childcare as an argument for why the United States shouldn’t.President Richard Nixon vetoed the bill,arguing that it would “commit the vast moral authority of the National Government to the side of communal approaches to child rearing over against the family-centered approach.”
In this case, “family-centered” meant the mother should care for the children at home while the father worked outside of it—regardless of whether this was something the parents could afford or desired to do. World War II remains the only time in U.S. history that the country came close to instituting universal childcare.
For some time, we’ve been focused on the efforts of Walmart to launch and grow a care delivery business, especially as it has piloted an expanded primary care clinic offering in a handful of states. We’ve long thought that access to basic care at the scale that Walmart brings could be transformative, given that more than half of Americans visit a Walmart store every week. Along those same lines, we’ve always wondered why Dollar General and Dollar Tree—each with around four times as many retail locations as Walmart—haven’t gotten into the retail clinic or pharmacy businesses.
(Part of the answer is ultra-lean staffing—this piece gives a good sense of the basic, and troubling, economics of dollar stores.) Now, as the federal government ramps up its efforts to widely distribute the COVID vaccines, it turns out that the CDC is actively discussing a partnership with Dollar General to administer the shots.
A fascinating new paper (still in preprint) from researchers at Yale shows why this could be a true gamechanger. The Biden administration, through its partnership with national and independent pharmacy providers, aims to have a vaccination site within five miles of 90 percent of the US population by next week. Compared to those pharmacy partners, researchers found,Dollar General stores are disproportionately located in areas of high “social vulnerability”, with lower income residents and high concentrations of disadvantaged groups. Particularly in the Southeast, a partnership with Dollar General would vastly increase access for low-income Black and Latino residents, allowing vaccine access within one mile for many, many more people. And the partnership could form the basis for future expansions of basic healthcare services to vulnerable and rural communities, particularly if some of the $7.5B in funding for COVID vaccine distribution went to helping dollar store locations bolster staffing and equipment to deliver basic health services. We’ll be watching with interest to see if the potential Dollar General partnership comes to fruition.
As health systems look to address the “social determinants of health”, one obvious but often overlooked place to start is with their own employees. The left side of the graphic below shows forecasted employment growth and salaries across a range of healthcare occupations. Many of the fastest-growing healthcare jobs—including home health and personal aides, medical assistants, and phlebotomists—are among the lowest-paid.
Case in point: home health and personal care aides are among the top 20 fastest-growing occupations in the US, and median wage for these jobs is only about $12 per hour, or around 200 percent of the federal poverty level—well below the living wage in many parts of the nation. (Note that this analysis does not include support staff who are not healthcare specific, like custodial or dietary workers, so the number of low-wage workers at health systems is likely higher.)
Among of the many struggles lower-income healthcare employees face is finding affordable housing. Using fair market rent data from the US Department of Housing and Urban Development, the right side of the graphic shows that healthcare support workers, even at the 90th percentile salary level, struggle to afford rent in the majority of the 50 largest US metros areas. In particular, home health aides in the top decile of earners can only afford rent in 14 percent of major cities.
These disparities have caught the attention of lawmakers. The $400B in President Biden’s proposed infrastructure plan devoted to home healthcare for seniors includes tactics to increase the wages and quality of life for these caregivers. But as we await policy solutions, health systems should pay careful attention to issues of housing insecurity and other structural challenges facing their workers and look to increase wages and provide targeted support to these critical team members.
In 2018, a short video circulated on WhatsApp claiming that the MMR vaccine was designed by Indian Prime Minister Narendra Modi to stop the population growth of Muslims. Subsequently, hundreds of madrassas across western Uttar Pradesh refused to allow health departments to vaccinate their constituents.
In 2020, a three-minute video claiming that the coronavirus vaccination campaign was secretly a plan by Bill Gates to implant trackable microchips in people wasone of the most widely shared pieces of misinformation online. Alongside a torrent of online COVID-19 vaccine falsehoods and conspiracy theories, sources of medical mis- and disinformation are fostering distrust in COVID-19 vaccines, undermining immunization efforts, and demonstrating how poor information is a determinant of health.
Medical misinformation, referring to inaccurate or unverified information that can drive misperceptions about medical practices or treatments, has flooded the infosphere (all types of information available online). Examples can vary from overrepresentations of anecdotes claiming that complications occurred following inoculation to misinterpretations of research findings by well-meaning individuals.
Considering the many ways in which medical misinformation can shape health behaviors, researchers at the Oxford Internet Institute recently suggested that the infosphere should be classified as a social determinant of health (SDOH) (designated alongside general socioeconomic, environmental, and cultural conditions). This classification, they argue, properly accounts for the correlation between exposure to poor quality information and poor health outcomes.
The connection between information quality and health has been especially pronounced during the COVID-19 pandemic. A 2021 study found that amongst those who indicated that they would definitely take a COVID-19 vaccine, exposure to misinformation induced a decline in intent of 6.2% in the U.K. and 6.4% in the U.S. Further, misinformation that appeared to be science-based was found to be especially damaging to vaccination intentions. These findings are particularly concerning considering the fact that during the pandemic, the 147 biggest anti-vaccine accounts on social media (which often purport to be science-based) gained 7.8 million followers in the first half of 2020, an increase of 19%.
During an unprecedented health crisis, medical misinformation within the infosphere is leaving both individuals and communities vulnerable to poor health outcomes.Those who are unvaccinated are at a higher risk of infection and increase the likelihood of community transmission. This places undue burden on those who cannot get vaccinated—due to inequities and/or preexisting conditions—and increases opportunities for variants to continue to mutate into more infectious and/or deadly forms of the virus. Poor quality information within the infosphere is undermining immunization efforts and threatens to prolong the ark of the pandemic.
Leveraging Healthcare Provider Influence in the Battle Against Poor Quality Information
Healthcare providers are uniquely suited to respond to this challenge. Throughout the pandemic, majorities of U.S. adults have identified their doctors and nurses as the most trustworthy sources of information about the coronavirus. In fact, 8 in 10 U.S. adults said that they are very or somewhat likely to turn to a doctor, nurse, or other healthcare provider when deciding whether or not to get a COVID-19 vaccine.
This influence is especially pertinent considering the state of vaccine resistance across the globe. In March 2021, a Kaiser Family Foundation poll found that 37% of U.S. respondents indicated some degree of resistance to vaccination. If that percentage of Americans remain unvaccinated, the country will be short of what is needed to achieve herd immunity (likely 70% or more vaccinated). Similar levels of resistance to vaccination remain high in countries across the globe, such as Lebanon, Serbia, Paraguay, and France.
Although medical misinformation is contributing to high rates of refusal, it is important to note that drivers of vaccine resistance are complex and intersectional. Vaccine distrust or refusal may be rooted in exposure to anti-vaccine rhetoric, racial injustice or medical exploitation in healthcare, fears that vaccine development was rushed, and/or other drivers. For this reason, responses must be tailored to unique individual or communal motivations. For example, experts have pressed the critical need for vaccine distrust within Black communities to be approached not as a shortcoming of community members, but as a failure of health systems to prove themselves as trustworthy.
With regard to resistance rooted in anti-COVID-19 vaccine misinformation, healthcare providers are leveraging their unique influence through novel, grassroots approaches to encourage vaccine uptake. In North Dakota, providers are recording videos and sending out messages to their patients communicating that they have been vaccinated and explaining why it is safe to do the same. On social media, a network of female doctors and scientists across various social media pages, such as Dear Pandemic (82,000 followers) and Your Local Epidemiologist (181,000 followers), are collaborating to answer medical questions, clear up misperceptions about COVID-19 vaccines, and provide communities with accurate information about the virus. Similarly, the #BetweenUsAboutUs online campaign is elevating conversations about vaccines with Black doctors, nurses, and researchers in an effort to increase vaccine confidence in BIPOC communities.This campaign is especially critical considering the fact that BIPOC communities are often the target of anti-vaccine groups in an effort to exploit existing, rational distrust in health systems.
In addition to these timely responses, evidence-based interventions offer promising opportunities for healthcare providers to improve vaccine uptake amongst their patients.For example, there is a growing consensus around the practice of motivational interviewing (MI).
MI is a set of patient-centered communication techniques that aim to enhance a patient’s intrinsic motivation to change health behaviors by tapping into their own arguments for change. The approach is based on empathetic, nonjudgmental patient-provider dialogue. In other words, as opposed to simply telling a patient why they should get vaccinated, a provider will include the patient in a problem-solving process that accounts for their unique motivations and helps them discover their own reasons for getting vaccinated.
When applying MI techniques to a conversation with a patient who is unsure if they should receive a vaccine, providers will use an “evoke-provide-evoke” approach where they will ask patients: 1) what they already know about the vaccine; 2) if the patient would like additional information about the vaccine (if yes, then provide the most up to date information); and 3) how the new information changes how they are thinking or feeling about vaccination. During these conversations, the MI framework encourages providers to ask open-ended questions, practice reflective listening, offer affirmations, elicit pros and cons of change, and summarize conversations, amongst other tools.
Numerous studies show motivational interviewing to be effective in increasing vaccine uptake. For example, one randomized controlled trial found that with parents in maternity wards, vaccine hesitancy fell by 40% after participation in an educational intervention based on MI. Given its demonstrated effectiveness, MI is likely to help reduce vaccine hesitancy during the COVID-19 pandemic.
With infectious disease outbreaks becoming more likely and resistance to various vaccines increasing across the globe, continuing to leverage healthcare providers’ unique influence through grassroots campaigns while honing motivational interviewing skills as a way to combat mis- and disinformation in the infosphere may prove critical to advancing public health now and in the future.
There’s widespread agreement that it’s important to help older adults and people with disabilities remain independent as long as possible. But are we prepared to do what’s necessary, as a nation, to make this possible?
That’s the challenge President Joe Biden has put forward with his bold proposal to spend $400 billion over eight years on home and community-based services, a major part of his $2 trillion infrastructure plan.
It’s a “historic and profound” opportunity to build a stronger framework of services surrounding vulnerable people who need considerable ongoing assistance, said Ai-jen Poo, director of Caring Across Generations, a national group advocating for older adults, individuals with disabilities, families and caregivers.
It comes as the coronavirus pandemic has wreaked havoc in nursing homes, assisted living facilities and group homes, killing more than 174,000 people and triggering awareness of the need for more long-term care options.
“There’s a much greater understanding now that it is not a good thing to be stuck in long-term care institutions” and that community-based care is an “essential alternative, which the vast majority of people would prefer,” said Ari Ne’eman, senior research associate at Harvard Law School’s Project on Disability.
“The systems we do have are crumbling” due to underfunding and understaffing, and “there has never been a greater opportunity for change than now,” said Katie Smith Sloan, president of LeadingAge, at a recent press conference where the president’s proposal was discussed. LeadingAge is a national association of more than 5,000 nonprofit nursing homes, assisted living centers, senior living communities and home care providers.
“Though this [proposal] is a necessary step to strengthen our long-term care system, politically it will be a challenge,” suggested Joseph Gaugler, a professor at the University of Minnesota’s School of Public Health, who studies long-term care.
Even advocates acknowledge the proposal doesn’t address the full extent of care needed by the nation’s rapidly growing older population. In particular, middle-income seniors won’t qualify directly for programs that would be expanded. They would, however, benefit from a larger, better paid, better trained workforce of aides that help people in their homes — one of the plan’s objectives.
“This [plan] isn’t everything that’s needed, not by any step of the imagination,” Poo said. “What we really want to get to is universal access to long-term care. But that will be a multistep process.”
Understanding what’s at stake is essential as communities across the country and Congress begin discussing Biden’s proposal.
The services in question.Home and community-based services help people who need significant assistance live at home as opposed to nursing homes or group homes.
Services can include home visits from nurses or occupational therapists; assistance with personal care such as eating or bathing; help from case managers; attendance at adult day centers; help with cooking, cleaning and other chores; transportation; and home repairs and modifications. It can also help pay for durable medical equipment such as wheelchairs or oxygen tanks.
The need. At some point, 70% of older adults will require help with dressing, hygiene, moving around, managing finances, taking medications, cooking, housekeeping and other daily needs, usually for two to four years. As the nation’s aging population expands to 74 million in 2030 (the year all baby boomers will have entered older age), that need will expand exponentially.
Younger adults and children with conditions such as cerebral palsy, blindness or intellectual disabilities can similarly require significant assistance.
The burden on families. Currently, 53 million family members provide most of the care that vulnerable seniors and people with disabilities require — without being paid and often at significant financial and emotional cost. According to AARP, family caregivers on average devote about 24 hours a week, to helping loved ones and spend around $7,000 out-of-pocket.
This reflects a sobering reality: Long-term care services are simply too expensive for most individuals and families. According to a survey last year by Genworth, a financial services firm, the hourly cost for a home health aide averages $24. Annually, assisted living centers charge an average $51,600, while a semiprivate room in a nursing home goes for $93,075.
Medicare limitations. Many people assume that Medicare — the nation’s health program for 61 million older adults and people with severe disabilities — will pay for long-term care, including home-based services. But Medicare coverage is extremely limited.
In the community, Medicare covers home health only for older adults and people with severe disabilities who are homebound and need skilled services from nurses and therapists. It does not pay for 24-hour care or care for personal aides or homemakers. In 2018, about 3.4 million Medicare members received home health services.
In nursing homes, Medicare pays only for rehabilitation services for a maximum of 100 days. It does not provide support for long-term stays in nursing homes or assisted living facilities.
Medicaid options. Medicaid — the federal-state health program for 72 million children and adults in low-income households — can be an alternative, but financial eligibility standards are strict and only people with meager incomes and assets qualify.
Medicaid supports two types of long-term care: home and community-based services and those provided in institutions such as nursing homes. But only care in institutions is mandated by the federal government. Home and community-based services are provided at the discretion of the states.
Although all states offer home and community-based services of some kind, there’s enormous variation in the types of services offered, who is served (states can set caps on enrollment) and state spending. Generally, people need to be frail enough to need nursing home care to qualify.
Nationally, 57% of Medicaid’s long-term care budget goes to home and community-based services — $92 billion in the 2018 federal budget year. But half of states still spend twice as much on institutional care as they do on community-based care. And 41 states have waiting lists, totaling nearly 820,000 people, with an average wait of 39 months.
Based on the best information available, between 4 million and 5 million people receive Medicaid-funded home and community-based services — a fraction of those who need care.
Workforce issues. Biden’s proposal doesn’t specify how $400 billion in additional funding would be spent, beyond stating that access to home and community-based care would be expanded and caregivers would receive “a long-overdue raise, stronger benefits, and an opportunity to organize or join a union.”
Caregivers, including nursing assistants and home health and personal care aides, earn $12 an hour, on average. Most are women of color; about one-third of those working for agencies don’t receive health insurance from their employers.
By the end of this decade, an extra 1 million workers will be needed for home-based care — a number of experts believe will be difficult, if not impossible, to reach given poor pay and working conditions.
“We have a choice to keep these poverty-wage jobs or make them good jobs that allow people to take pride in their work while taking care of their families,” said Poo of Caring Across Generations.
Next steps.Biden’s plan leaves out many details. For example: What portion of funding should go to strengthening the workforce? What portion should be devoted to eliminating waiting lists? What amount should be spent on expanding services?
How will inequities of the current system — for instance, the lack of accessible services in rural counties or for people with dementia — be addressed? “We want to see funding to states tied to addressing those inequities,” said Amber Christ, directing attorney of the health team at Justice in Aging, an advocacy organization.
Meanwhile, supporters of the plan suggest it could be just the opening of a major effort to shore up other parts of the safety net. “There are huge gaps in the system for middle-income families that need to be addressed,” said David Certner, AARP’s legislative counsel.
Reforms that should be considered include tax credits for caregivers, expanding Medicare’s home health benefit and removing the requirement that people receiving Medicare home health be homebound, said Christ of Justice in Aging.
”We should be looking more broadly at potential solutions that reach people who have some resources but not enough to pay for these services as well,” she said.