Q. Why is health care affordability such a pressing public health issue?

A. Affordability is a widespread problem even as fewer Americans go without health insurance. The amount people spend directly on health care (not including insurance premiums), known as “out-of-pocket” costs, has been growing faster than inflation and this has several important implications. Surveys consistently show that people delay or forgo care due to cost, worry about their ability to pay for health care bills, and incur medical debt.

Health care affordability—or a lack thereof—can harm individual health. Affordability impacts whether people can get the care they need, like insulin to manage their diabetes or following up on a mammogram. If those are too costly, people will delay or skip care, which has significant impacts down the line on both health outcomes and cost.

As health care expenses continue to go up, household budgets have to adjust—which means people can’t afford the same kind of groceries or housing they’re used to. That is a public health problem, which has particularly burdensome effects on lower-income, high-need families.

Finally, rising costs create an increased risk that people will face catastrophic health care situations that have massive financial implications, with consequences ranging from mortgaging their homes to personal bankruptcy. That also has a direct consequence on people’s well-being.

Q. What are the biggest challenges facing the next administration on health care affordability?

A. The biggest challenge is simple: The forces that make health care increasingly unaffordable are complicated.

The biggest threat we’ve found is consolidation in medicine. For example, there is a growing trend of hospitals and other corporate entities buying up physician practices and then negotiating as a unit with health insurance companies, driving up prices significantly.

To address the root causes, we have to recognize where medical monopolies are forming and try to prevent them from passing on inflated prices to consumers.

Q. What are your top policy recommendations to address health care affordability? 

A. There are two kinds of solutions to improve affordability: the band-aids and the systemic shifts.

The band-aids are short-term solutions that can improve affordability for folks in need now, including providing government subsidies to help consumers afford their copays. This assistance would alleviate the immediate price shock for patients and make care more accessible, which is a good thing. However, there is a downside—with the government on the hook for the bill, health care conglomerates are incentivized to raise prices even further. The short-term benefit can create long-term challenges.

Another band-aid option is to cap the prices that, for example, hospitals can charge. This could get closer to the heart of the issue but brings its own serious risk; providers could opt out of the market for certain services, which could create shortages. Nailing that balance is a real challenge.

Then there are efforts to address the underlying forces that drive price increases—chief among them antitrust enforcement to address the vertical integration currently occurring in health care, which is when independent physicians, hospitals, and physician groups merge to create a health care network.

The combined powers of large consolidated health systems and other types of health care corporations mean that some entities can set health care prices with little oversight or pushback. The federal government has antitrust laws in place to address these sorts of monopolies, but it has traditionally been reluctant to challenge health care mergers, especially when those mergers involve vertical integration or other types of consolidation.

Enforcing these antitrust laws is a very complicated task that requires coordination between the federal government and state attorneys general, as well as significant political will to stand up to the influence of health systems that have real sway in their communities.

Given the challenges and drawbacks of band-aid solutions and systemic shifts, the ideal policy recommendations would strike a balance of short- and long-term solutions. Instituting present-day policies that save consumers money while building to break up the vertical monopolies dominating health care is the best-case scenario to create real and long-lasting relief for consumers.

Q. What’s the evidence supporting those recommendations? 

A. My Harvard Chan School colleague Anna Sinaiko and I have found that vertical integration is increasing—and driving price increases. We’ve also found that vertical integration of primary care physicians and large health systems does drive an increase in per-patient spending—but has no impact on readmission rates, meaning the promise of “integrated” care remains elusive and the extra spending associated with integration is not necessarily making patients healthier.

The cost increases alone are important for public health, which we know because there is a strong body of research indicating the importance of health care affordability to people’s physical and mental well-being.

For example, Katherine Baicker, a former Harvard Chan School economist now at the University of Chicago, led several papers studying the impact of Medicaid expansion in Oregon following passage of the Affordable Care Act. The studies found self-reported physical health benefits, increased rates of diabetes detection and management, and better follow-through on preventive care. Beyond the physical benefits, the peace of mind offered by health coverage was noticeable. Newly enrolled Medicaid beneficiaries demonstrated lower rates of depression, thanks in part to reduced financial strain. By making care more affordable and accessible, we can significantly improve health.

Q. What do you hope could be accomplished to make health care more affordable in the next four years? 

A. Policymakers need to consider both short-term fixes to help people most affected by high health care prices and longer-term policies that get at the root causes of declining affordability. Some “band-aids” could be readily implemented—including extending increased health insurance subsidies that were put into place during the public health emergency [of the COVID pandemic] to help people afford their coverage.

We could also pursue targeted policies, such as expanding limits on out-of-pocket costs for critical medicines—for example, medicines that control asthma and cardiovascular disease—similar to the recent policies enacted to cap out-of-pocket costs for insulin. These high-value treatments that keep people of out hospitals could be partially paid for by savings on health care expenditures and yield better outcomes.

On the antitrust enforcement side, hope for action in the immediate future is mixed at best. Efforts to regulate health care prices at the federal and state level may have some role to play going forward, although such efforts face substantial political headwinds. For example, federal law permitted the Centers for Medicare and Medicaid to negotiate prices with manufacturers for a small number of drugs. Manufacturers sued the government but the price negotiations proceeded, with the results announced earlier this year. The federal government should try to learn from its first foray into price negotiation in Medicare and look for ways to continue to leverage its buying power to keep some of the highest cost drugs accessible and affordable—but those benefits only relate to Medicare. Whether and how Medicare’s new price limits can affect privately insured patients remains unclear. I hope that the next administration will make progress in this area, but true change will likely take longer than four years.

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By Amber Dance

CDC plans overhaul amid critiques of latest loosened recommendations 

After more than two years of a bungled U.S. COVID response, the CDC is acknowledging its mistakes and pledging to improve.

“In our big moment, our performance did not reliably meet expectations,” said agency director Dr. Rochelle Walensky on Aug. 17. She promised a new agency culture with a stronger focus on action for public health.

The changes are Walensky’s response to a report based on interviews with about 120 CDC employees. The report said it “takes too long for CDC to publish its data and science” and that the guidance is “confusing and overwhelming,” according to Sasha Pezenik at ABC News.

Part of the overhaul includes restructuring the communications office and updating the website with simpler language.

The slow release of CDC research findings stemmed, in part, from a promotion system that incentivized publication in the agency’s Morbidity and Mortality Weekly Report, report Lena H. Sun and Dan Diamond at The Washington Post. The CDC now plans to release more data by preprint, which is faster.

One of the problems has been a focus on research rather than public health management, reports Joyce Frieden at MedPage Today. “CDC is a great organization, but it has always functioned like a big academic health system and not an emergency response entity,” Dr. Georges Benjamin, executive director of the American Public Health Association, told her.

Another problem was that the staff in charge of outbreaks changed every few months, creating a disjointed response and confusion about who was in charge. According to The Post, Walensky is considering a minimum six-month rotation for staffers charged with handling outbreaks.

The shakeup comes on the heels of criticism over CDC’s latest loosening of COVID-19 guidelines. Notably, the agency eliminated the recommendation for people exposed to COVID-19 to quarantine. It continues to recommend isolation for at least five days for people who have symptoms or test positive.

Some experts noted the agency seems to be ”leading from behind,” acknowledging what people are already doing rather than recommending what they should do.

The latest guidelines are “leaving decision-making mainly to individuals and local officials who lack public health training,” opine professors Wendy Netter Epstein and Daniel Goldberg in the Los Angeles Times. Putting the onus on individuals to avoid illness disproportionately harms low-income communities and people of color, they write.

Meanwhile, the U.S. seems to be repeating its public health missteps with monkeypox. The nation has more cases than any other country in the world.

Outsiders praised Walensky’s plans to fix the CDC, but noted Congressional approval and funding will be needed for some changes — and that it will be difficult to change the agency’s culture, as Helen Branswell reported at STAT.

“It’s an agency run by geeks. It’s run by doctors and Ph.D.s,” Dr. Jay Varma, director of the Cornell Center for Pandemic Prevention and Response and a former CDC employee told Branswell. “They’re really good at hypothesis-driven research and analyzing information and making predictions about what might happen. What they’re really bad at is managing people in an effective way.”

Study finds COVID-related discrimination on AirBnb

Pandemic scapegoating led to a 12% reduction in AirBnb bookings for hosts with Asian-sounding names, according to a new Harvard Business School working paper.

The researchers based their study on data from New York City in 2019 and 2020, using the quantity of reviews as a proxy for bookings.

The authors suggest the platform could minimize racism by hiding host names and photos until a reservation is made. AirBnb is eager to counter discrimination and looking into the research, reports Anissa Gardizy at The Boston Globe.

This latest finding is an example of discrimination against members of the Asian American and Pacific Islander (AAPI) community that has, at times, been much more sinister, even violent, during the pandemic. The latest report from Stop AAPI Hate documented nearly 11,500 hate incidents through March 2022 — mostly harassment but also physical assault and shunning.

“If you’re only watching the news, you aren’t getting the full picture of what AAPIs are experiencing,” the organization’s co-founder Russell Jeung told Michelle De Pacina at Yahoo! News.

White House promises new boosters by September

White House COVID coordinator Dr. Ashish Jha has predicted that updated booster shots could be available for adults within a couple of weeks, assuming the FDA and CDC give the new formulations their approval, reports Cheyenne Haslett at ABC News.

Jha also expressed hope that the government would be able to buy enough doses for everyone in the U.S., but the Biden administration is waiting for Congress to open its purse. So far, it’s only been able to afford a contract for 171 million doses from Pfizer and Moderna.

That might be enough — after all, only 108 million people got their first booster shot.

A recent poll from the University of Michigan found that among adults over 50 who have already received at least one vaccine dose, 61% are very likely to seek the new booster.

These new mRNA vaccines, which target the omicron BA.4/5 spike protein as well as the original spike, will be authorized based not on human trials, but on their performance in mice, explains Rob Stein at NPR. Data from human trials aren’t expected until mid-autumn.

The United Kingdom has already approved a new booster from Moderna, but that one targets the original omicron variant, for which human data are already available. U.S. regulators chose to take aim at the more recently circulating variants.

Last week Novavax requested authorization for its booster shot — a protein-based vaccine tailored to the original coronavirus strain. At an FDA meeting earlier this summer, the company said this shot generated significant antibodies against omicron BA.5 without needing any change to the formula.

If Novavax is authorized alongside mRNA boosters, it could set up a debate over which type of booster is the best to maximize Americans’ immunity before the upcoming winter, when COVID is expected to surge yet again.

Experts are also likely to be debating the best time for people to get a COVID booster, because earlier isn’t always better.

“The concern is that someone who gets a shot in, say, September, may lose a chunk of their protection if the peak of the season is going to be in February,” writes Andrew Joseph at STAT. “Complicating the process is that scientists don’t have a sense yet — after only two winters with SARS-CoV-2 — about just when the virus might peak.”

Jha also said that the White House may soon stop purchasing COVID-19 vaccines, tests and treatments on behalf of Americans, reports Brenda Goodman at CNN.

“My hope is that in 2023, you’re going to see the commercialization of almost all of these products,” Jha said at a U.S. Chamber of Commerce Foundation event. “Some of that is actually going to begin this fall.”

Neurological consequences of COVID may linger for years

Brain fog can persist for at least two years following a bout with COVID-19, according to a new study in The Lancet Psychiatry.

Risks for other neurological conditions, such as dementia and psychosis, also remains heightened for years, and at rates higher than those for other respiratory infections.

The study was based on the medical records of about 1.25 million people who were diagnosed with COVID, mostly in the U.S.

It found that the risk for mood disorders, such as anxiety and depression, was higher in the months immediately following illness but dropped quickly.

Children who had COVID were less likely to suffer neurological consequences than adults, but still had higher risk for seizures and psychiatric disorders than kids recovering from other infections.

The study authors, from the University of Oxford, characterized the absolute risk for neurological consequences as relatively low overall, but “nontrivial,” reports Elizabeth Cooney at STAT.

The study had several caveats. For example, some neurological symptoms may go unrecorded by providers.

“This is only pickup up very blunt stuff,” said Dr. Steven Deeks of UCSF, who was not involved in the study. “At the end of the day, it provides additional proof that long COVID is real, that some people can have profound symptoms, and that they can persist for a couple of years.”

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Starting in 2022, there are new protections that prevent surprise medical bills. If you have private health insurance, these new protections ban the most common types of surprise bills. If you’re uninsured or you decide not to use your health insurance for a service, under these protections, you can often get a good faith estimate of the cost of your care up front, before your visit. If you disagree with your bill, you may be able to dispute the charges. Here’s what you need to know about your new rights.

What are surprise medical bills?

Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or an out-of-network facility, even unknowingly, your health plan may not have covered the entire out-of-network cost. This could have left you with higher costs than if you got care from an in-network provider or facility. In addition to any out-of-network cost sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.

People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing.

What are the new protections if I have health insurance?

If you get health coverage through your employer, a Health Insurance Marketplace®,[1] or an individual health insurance plan you purchase directly from an insurance company, these new rules will:

Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).

Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services. Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.

Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

What if I don’t have health insurance or choose to pay for care on my own without using my health insurance (also known as “self-paying”)?

If you don’t have insurance or you self-pay for care, in most cases, these new rules make sure you can get a good faith estimate of how much your care will cost before you receive it.

What if I’m charged more than my good faith estimate?

For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file your dispute claim within 120 days of the date on your bill.

What if I do not have insurance from an employer, a Marketplace, or an individual plan? Do these new protections apply to me?

Some health insurance coverage programs already have protections against surprise medical bills. If you have coverage through Medicare, Medicaid, or TRICARE, or receive care through the Indian Health Services or Veterans Health Administration, you don’t need to worry because you’re already protected against surprise medical bills from providers and facilities that participate in these programs.

What if my state has a surprise billing law?

The No Surprises Act supplements state surprise billing laws; it does not supplant them. The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply. For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process.

As another example, if your state has an All-payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate.

Where can I learn more?

Still have questions? Visit CMS.gov/nosurprises, or call the Help Desk at 1-800-985-3059 for more information. TTY users can call 1-800-985-3059.

CMS.gov | Contributed

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The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), is awarding $20 million in American Rescue Plan (ARP) grant funding to State-based Marketplaces (SBMs) to increase consumer access to affordable, comprehensive health insurance coverage. The grants will be used by 21 SBMs to modernize IT systems and/or conduct targeted consumer outreach activities to help make health care coverage enrollment smoother. As a result, consumers will have access to increased financial assistance and eligibility determinations will be made faster.

“It should be easy and convenient for anyone to sign up for a health care plan,” said Health and Human Services Secretary Xavier Becerra. “This investment from the American Rescue Plan will help states cover more uninsured residents while providing a smooth transition to other sources of health coverage for Medicaid enrollees who may lose coverage. The Biden-Harris Administration is committed to ensuring access to health care for everyone is possible, and will continue to make improvements in the system.”

The grant funding issued today not only helps states provide swifter eligibility and enrollment processes for new consumers purchasing Marketplace coverage, but also helps states to reassess current enrollees’ eligibility for increased savings made available through the ARP. The ARP reduced health coverage costs for consumers with many consumers finding plans for $10 or less per month. As a result of the ARP, most consumers purchasing Marketplace coverage are now eligible for increased Advance Payments of the Premium Tax Credit (APTC) that reduce their portion of monthly premiums.

“When we improve access to quality, affordable health coverage – people sign up. With these American Rescue Plan funds, we are investing in increasing consumer education and awareness about the greater financial assistance now available,” said CMS Administrator Chiquita Brooks-LaSure. “Producing consumer notices in additional languages and targeting outreach to the underinsured and uninsured are just a few approaches states will use to connect members of these communities, particularly vulnerable and underserved populations, to affordable health coverage.”

The 21 SBMs that received the ARP grant funding include the District of Columbia and the following states: Arkansas, California, Colorado, Connecticut, Idaho, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, and Washington. States with a Federally-Facilitated Marketplace (FFM) were not eligible for this funding opportunity. Grant award amounts range from $500,000 to $1,107,392, and are based on the SBM model and number of successful applicants. The period of performance is from September 10, 2021 through September 9, 2022.

For more information on the 21 SBMs that received the funding and use of the funds, please visit:

https://www.cms.gov/files

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That’s especially true for the country’s children. More than one-third of kids get their health coverage through the program, and 70% of children from families with incomes under 200% of the federal poverty line rely on it. It’s also a story of racial equity, since the share of Black and Native American children on the program is nearly double that of white kids.

That means any near-term changes to the program could have big implications for a large chunk of the nation’s children and families, and especially families of color. The pandemic ushered in some key enhancements to boost Medicaid coverage, Joan Alker, executive director of the Center for Children and Families at Georgetown University, told journalists at last Friday’s 2021 National Fellowship via Zoom. But if these emergency measures go away when the pandemic subsides, families on the margins stand to lose health coverage.

Alker said she is closely watching several hot-button issues.

A big one is funding:

The Medicaid program is a partnership between states and the federal government, with the feds matching a given state’s funding at a set level, which varies by state according to an abstruse formula. The emergency coronavirus bill passed in March 2020 gave states a 6.2% bump in the matching rate. But that big funding boost is set to expire when the federally declared “public health emergency” ends. (Health and Human Services Secretary Xavier Becerra just renewed it for another 90 days last week.)

“This is a very big question for states: When it this going away?” Alker said.

The federal bonus funds came with strings attached: States couldn’t kick people off their Medicaid rolls unless they asked to be or moved out of state. While that might seem like a minor point, states that have been politically opposed to growing their Medicaid programs have long turned to bureaucratic strategies to winnow the ranks. For instance, before the pandemic, Texas relied on a system of automated monthly income checks, which resulted in thousands of kids losing coverage despite their eligibility.

“We call these red-tape losses,” Alker said. “We don’t have any red-tape losses right now.”

But that would change when the funding bump and its disenrollment restrictions expire. According to Alker, some states are eager to start paring their Medicaid rolls.

“Some states are keeping lists of people they’d like to kick off immediately,” Alker said. “We heard from our folks in Idaho they’ve got about 60,000 or 80,000 people they’d like to kick off immediately.”

The broader losses of coverage could be huge, Alker said.

“Now we’re awaiting guidance from the Biden administration on how states have to do this, how to make sure that kids and families don’t lose coverage for procedural reasons, but this is potentially a huge issue, because we could see hundreds of thousands, if not millions of kids and families losing their coverage when this disenrollment freeze is lifted.”

But while other states might be looking to reinstate some of the red tape around their Medicaid programs, Alker says that on the flip side, other states have streamlined enrollment, promoted the use of telehealth (especially important for behavioral health), ditched premiums and looked for other ways to expand access during and before the pandemic. And it’s not just blue states like New York or Massachusetts. Alker calls Alabama the “star of the South” for insuring nearly 97% of its kids.

Spend too long on the arid plains of Medicaid and CHIP policy and it can become easy to forget why it matters and what’s at stake. A family who loses coverage before getting hit with a medical emergency potentially is liable to face financial devastation. But some of the consequences are more subtle than that, as Alker reminded journalists.

For a child with asthma, a condition that disproportionately impacts Black children, it could mean not having access to doctors and prescriptions for inhalers, she said. That in turns can lead to more missed school, which is correlated with lower rates of high school graduation. Alker and her colleagues at Georgetown partnered with the Commonwealth Fund last year for a report that detailed the long-term benefits of Medicaid for kids. The report links Medicaid enrollment to everything from lower rates of chronic disease to higher birthweights, higher rates of education and earnings, and even reduced mortality.

“We get in these budget debates, and we’re just looking at a year in a state budget, but thinking about the long-term consequences for kids and families and communities, when these kids are having trouble accessing the care they need, really is a big issue,” Alker said.

Ryan White | Columnist

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Enrollment in Medicaid soared to record levels during the pandemic. With more than 80 million people now getting health coverage through Medicaid and the Children’s Health Insurance Program, more Americans rely on the public safety net than ever before.

That’s especially true for the country’s children. More than one-third of kids get their health coverage through the program, and 70% of children from families with incomes under 200% of the federal poverty line rely on it. It’s also a story of racial equity, since the share of Black and Native American children on the program is nearly double that of white kids.

That means any near-term changes to the program could have big implications for a large chunk of the nation’s children and families, and especially families of color. The pandemic ushered in some key enhancements to boost Medicaid coverage, Joan Alker, executive director of the Center for Children and Families at Georgetown University, told journalists at last  Friday’s 2021 National Fellowship via Zoom. But if these emergency measures go away when the pandemic subsides, families on the margins stand to lose health coverage.

Alker said she is closely watching several hot-button issues.

A big one is funding: The Medicaid program is a partnership between states and the federal government, with the feds matching a given state’s funding at a set level, which varies by state according to an abstruse formula. The emergency coronavirus bill passed in March 2020 gave states a 6.2% bump in the matching rate. But that big funding boost is set to expire when the federally declared “public health emergency” ends. (Health and Human Services Secretary Xavier Becerra just renewed it for another 90 days last week.)

“This is a very big question for states: When it this going away?” Alker said.

The federal bonus funds came with strings attached: States couldn’t kick people off their Medicaid rolls unless they asked to be or moved out of state. While that might seem like a minor point, states that have been politically opposed to growing their Medicaid programs have long turned to bureaucratic strategies to winnow the ranks. For instance, before the pandemic, Texas relied on a system of automated monthly income checks, which resulted in thousands of kids losing coverage despite their eligibility.

“We call these red-tape losses,” Alker said. “We don’t have any red-tape losses right now.”

But that would change when the funding bump and its disenrollment restrictions expire. According to Alker, some states are eager to start paring their Medicaid rolls.

“Some states are keeping lists of people they’d like to kick off immediately,” Alker said. “We heard from our folks in Idaho they’ve got about 60,000 or 80,000 people they’d like to kick off immediately.”

The broader losses of coverage could be huge, Alker said.

“Now we’re awaiting guidance from the Biden administration on how states have to do this, how to make sure that kids and families don’t lose coverage for procedural reasons, but this is potentially a huge issue, because we could see hundreds of thousands, if not millions of kids and families losing their coverage when this disenrollment freeze is lifted.”

But while other states might be looking to reinstate some of the red tape around their Medicaid programs, Alker says that on the flip side, other states have streamlined enrollment, promoted the use of telehealth (especially important for behavioral health), ditched premiums and looked for other ways to expand access during and before the pandemic. And it’s not just blue states like New York or Massachusetts. Alker calls Alabama the “star of the South” for insuring nearly 97% of its kids.

Spend too long on the arid plains of Medicaid and CHIP policy and it can become easy to forget why it matters and what’s at stake. A family who loses coverage before getting hit with a medical emergency potentially is liable to face financial devastation. But some of the consequences are more subtle than that, as Alker reminded journalists.

For a child with asthma, a condition that disproportionately impacts Black children, it could mean not having access to doctors and prescriptions for inhalers, she said. That in turns can lead to more missed school, which is correlated with lower rates of high school graduation. Alker and her colleagues at Georgetown partnered with the Commonwealth Fund last year for a report that detailed the long-term benefits of Medicaid for kids. The report links Medicaid enrollment to everything from lower rates of chronic disease to higher birthweights, higher rates of education and earnings, and even reduced mortality. 

“We get in these budget debates, and we’re just looking at a year in a state budget, but thinking about the long-term consequences for kids and families and communities, when these kids are having trouble accessing the care they need, really is a big issue,” Alker said.

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COLUMBUS, Ohio (AP) — President Joe Biden pledged Tuesday that his $1.9 trillion rescue package would build on the promise of the Affordable Care Act, the hallmark legislation of Barack Obama’s presidency that became law 11 years ago.

Biden’s COVID-19 relief law pumps up “Obamacare” premium subsidies to address longstanding problems of affordability, particularly for people with middle-class incomes. More taxpayer assistance means, in effect, that consumers who buy their own policies through HealthCare.gov will pay hundreds of dollars less out of their own pockets.

“We have a duty not just to protect it, but to make it better and keep becoming a nation where health care is a right for all, not a privilege for a few,” Biden said at the James Cancer Hospital in Columbus, Ohio. “Millions of families will be able to sleep a little more soundly at night because they don’t have to worry about losing everything if they get sick.”

Biden’s speech in the capital of a political battleground state is part of a mini-blitz by the White House to highlight the relief package. Newly minted Health Secretary Xavier Becerra will echo Biden’s comments Tuesday in Carson City, Nevada, and join a Florida-themed Zoom event. Second gentleman Douglas Emhoff will pitch the aid in Omaha, Nebraska.

Yet events interrupted the push, as Biden needed to also address a mass shooting in Boulder, Colorado, that left 10 people dead. He spoke about the shooting and need for background checks before leaving for Ohio. And while touring a cancer center in Columbus, Biden was asked if he had the political capital to move forward on new gun control measures.

“I hope so,” said Biden, crossing his fingers. “I don’t know. I haven’t done any counting yet.”

On health care, the numbers suggest that consumers’ fears about medical costs could be eased by the new rescue package.

The COVID-19 legislation cuts premiums paid by a hypothetical 64-year-old making $58,000 from $1,075 a month to about $413, based on Congressional Budget Office estimates. A 45-year-old making $19,300 would pay zero in premiums as compared with about $67 on average before the law. People who have even a brief spell of unemployment this year can get a standard plan for zero premium and reduced copays and deductibles.

“The ACA is over a decade old and this is literally the first time that Democrats have been successful at improving it,” said analyst Larry Levitt of the nonpartisan Kaiser Family Foundation. “Democrats have succeeded politically by selling the ACA’s protections for preexisting conditions, but affordability has always been a challenge. And now Democrats have successfully improved the premium help available under the law.”

New and existing customers will be able to take advantage of the savings starting April 1 by going to HealthCare.gov. States that run their own health insurance markets will offer the same enhanced assistance, although timetables for implementation may vary.

The administration announced Tuesday that people will now be able to enroll for subsidized HealthCare.gov coverage until Aug. 15, an extension of three months. Biden has opened up the health insurance markets as part of his coronavirus response.

The Centers for Medicare and Medicaid Services, which runs the insurance markets, also said that additional savings for people who’ve been dealing with unemployment will be available through HealthCare.gov starting in early July. The richer subsidies were incorporated in the COVID-19 relief bill.

By spreading the word about the higher subsidies, the White House is hoping to super-charge enrollment. But the 11 million people who already have private plans through the health law will also benefit.

Republicans see Biden’s sweeter subsidies as an example of Democratic overreach on the COVID-19 bill. Policy consultant Brian Blase, a former health care adviser in the Trump White House, expects most of the additional taxpayer assistance will merely substitute for what private households would have otherwise paid.

Their complaints notwithstanding, Republicans may face a political dilemma. The higher health care subsidies are keyed to the pandemic and expire by the end of 2022. That will let Democrats set up election-year votes to make the new benefits permanent, or add even more.

The COVID-19 bill follows Biden’s strategy of building on the Obama-era health law to move the U.S. toward coverage for all.

Another provision offers a dozen or so holdout states led by Republicans a financial inducement to expand Medicaid to more low-income adults. So far there have been no takers.

It’s unclear how big a dent the Biden legislation will make in the number of uninsured people, which has risen to an estimated 33 million or more. But it represents the biggest expansion of federal help for health insurance since the ACA’s enactment.

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But will a Joe Biden presidency lead to real gains in the number of kids with insurance? Some observers are hopeful, while children’s advocacy groups are putting out their wish lists for the incoming administration. An estimated 726,000 children in the United States have lost their health insurance since 2016, when the youth uninsured rate reached a historic low, according to recently released research from the Georgetown Center for Children and Families. Last year, that uninsured rate experienced its largest annual increase in a decade, as 320,000 kids fell off the insurance rolls from 2018 to 2019.

What can be done? The American Academy of Pediatrics recently released a list of policy suggestions for the Biden-Harris transition team the organization says will strengthen the health of the nation’s 73 million children and improve access to care. While budget constraints caused by the pandemic could hamper some of these efforts, Dr. Melinda Williams-Willingham, chairwoman of the academy’s Committee on Federal Government Affairs, is optimistic the incoming president and his team will do more to prioritize health care access for kids.

The Georgia pediatrician said COVID-19 has highlighted the need for it more than ever. “People are so focused on the fact that children don’t seem to be impacted much by this pandemic when it comes to hospitalizations or death rates,” she said. “But what they don’t see is the mental health toll that it’s taking on our children. And unfortunately I feel that we are going to have another major crisis within this country when it comes to the mental health of children.”

She said more than half of her days are now spent treating kids for mental health issues, caused by factors such as increased isolation, missed school and financial stress in the household. The pediatric group’s recommendations to boost access include streamlining youth enrollment and retention in Medicaid and the Children’s Health Insurance Program; getting rid of state Medicaid waivers and other pending Medicaid rules that limit coverage; insuring all kids regardless of immigration status; increasing provider reimbursement for Medicaid; restricting health plans with narrow networks; and supporting the Affordable Care Act through legal and regulatory actions.

(Biden’s pick to lead the U.S. Department of Health and Human Services, Xavier Becerra, voted for the law as a congressman and defended it in court as California’s attorney general.) “When families lose their health care insurance, what I’ve seen is that children no longer receive their immunizations, and of course that makes them susceptible to infections,” Williams-Willingham said. “They also do not have access to the well-child checks that are critical to identify if the child has any developmental abnormalities, and so that when we’re able to provide those services for them, it’s delayed. So early intervention is key.”

When parents postpone care for their kids because they don’t have insurance, it can lead to far more serious health crises, the doctor noted. “Now instead of giving them a simple antibiotic to be able to clear up an infection, you may have a child that might need more intensive management of that infection or illness,” she said.

The report from Georgetown’s Center for Children and Families lays the blame on the rise in uninsured kids on such factors as Republican efforts to repeal the Affordable Care Act, reductions in funding for insurance outreach and enrollment, and proposed cuts and poor oversight of state Medicaid programs. The authors also point to the “climate of fear and confusion” among immigrant families that has caused fewer of them to enroll their children in public insurance programs.

Williams-Willingham said that in 2010, when Georgia switched to a new managed care program for Medicaid, many specialists stopped accepting the insurance. She had a patient with a hand injury but couldn’t find an orthopedic hand specialist who would see the child. Williams-Willingham said the injury eventually progressed to the point where the kid needed surgery from what was “an otherwise simple problem” to fix. “And I had to ask myself … am I still in the United States of America?” the pediatrician recalled. “It should not be so challenging to provide health care services to children.”

Giles Bruce • Health Reporter

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At a press conference before a speech to the Medical Committee for Human Rights in 1966, two years before his assassination, Dr. Martin Luther King Jr. noted, “Of all the forms of inequality, injustice in health is the most shocking and inhumane because it often results in physical death.”

King’s words come back to haunt us as the death statistics from COVID-19 roll in from every corner of the United States bearing the bad news.

According to new data from the Centers for Disease Control and Prevention, analyzed by The New York Times, African Americans and Latinos are three times more likely to become infected with the virus than white people. They are nearly twice as likely to die. Those statistics are grim markers of a disease that has hit America’s populations of color particularly hard.

What do those dismal numbers and the gaping health disparities they lay bare say about the refusal to expand Medicaid in some states, and the imposition of barriers that make expansion almost meaningless in others? Why are states continuing to turn down federal dollars to expand health care access during this time of historic need? Answers to those questions can help frame journalistic coverage as states prepare for new legislative sessions, where expansion will surely be on the agenda.

Recall that the Affordable Care Act, or ACA, expanded Medicaid to Americans with incomes up to 138 percent of the federal poverty level of $17,240 for a two-person family. But a 2012 U.S. Supreme Court decision made expansion optional. Legislatures in states that have not expanded, mostly in the South and Midwest, have refused to extend coverage to some of their poorest residents. Some 4.8 million people are in the so-called coverage gap: Their incomes are below the poverty level, and they are left out of the ACA because the law envisioned they’d be covered under the Medicaid expansion. They are too poor to buy commercial coverage and in many cases have too much money to qualify for regular Medicaid programs in their states because eligibility limits are so low.

I rang up Camara Phyllis Jones, a physician, epidemiologist, past president of the American Public Health Association, and recently a fellow at Harvard’s Radcliffe Institute for Advanced Study. Where does the health care that King worried about so long ago fit into America’s new reckoning with its racist past?

Before she even began to discuss health insurance, Jones noted that many people of color are working in jobs that have exposed them more to the coronavirus and left them less protected. Think: workers in meatpacking plants or bus drivers, not program analysts or accountants who can work from home. When people of color do become infected, Jones said, they are more likely to die because they are more burdened by chronic diseases often brought on by poor diets, less access to healthy foods, and polluted environments. Compounding those burdens are stringent Medicaid rules, including work and reporting requirements, even in states that have expanded the program. These rules make access to medical care difficult to obtain.

“All these factors have the root cause of racism,” Jones explained. She doesn’t think the infection rate or the death rate are primarily health issues. “They are based in racism and how different populations are valued, and perhaps a wrong idea of what populations use Medicaid,” she said.

Health equity in a state, she said, means valuing all individuals equally, recognizing and redefining historical injustices, and prioritizing resources according to need. That framework, or lack of it, helps explain why so many states have yet to expand Medicaid. It illuminates why three states – Idaho, Utah and Nebraska — whose voters approved expansion through ballot initiatives, and other states that have expanded, have imposed punitive or harsh requirements, such as compelling recipients to report periodically on efforts to find work or do hours of community service as a condition for retaining health insurance.

These are restrictions that Americans insured through their jobs or through the Affordable Care Act do not have to meet. The country has created a two-tired health insurance system based on racism.

Put another way, opposition to Medicaid expansion “is an ideological opposition, not a fact-based opposition to the ACA,” says Joan Alker who heads the Center for Children and Families at Georgetown University’s School of Public Policy. “It’s tied up with a hatred of the ACA, which was President Obama’s signature achievement.” Alker points out that some 400 studies show Medicaid expansion reduces deaths. “I’m not sure what more evidence anyone can provide.”

To see how this opposition leaves people in poorer health and more vulnerable to the effects of the current pandemic and future calamities, I looked at two states, Mississippi and Nebraska. In Mississippi, which has not expanded its Medicaid program, 13% of uninsured residents are white, 16% are African American, and 30% are Hispanic.

In Nebraska, where 90,000 residents have been uninsured, the legislature has refused six times to expand Medicaid. Residents are awaiting implementation of an expansion voters approved two years ago, but state bureaucrats have been slow to begin the program, now scheduled to start in October.

In Mississippi, health department statistics show that as of July 21, African Americans accounted for about 52% of deaths from COVID-19, though they make up about 38% of the population.

“A poor food environment and lack of health care make the South a really vulnerable place,” says Dr. Anne Cafer, an assistant professor or sociology at the University of Mississippi. “COVID has brought this out in a way we haven’t seen before. It has highlighted the fact that if we don’t improve access, we’ll have a higher percentage of the population that gets it.”

Cafer argues the nutritional deficits of COVID patients represent a drawn-out process that reveals the link between poor diets and diseases such as obesity, diabetes and heart disease. “COVID makes this process more immediate and brings it into sharper delineation.”

The solutions pose familiar challenges. How do you get more food in the food deserts of Mississippi communities, and how do you pay for the services such as dietitians and food counselors when so much of the population in need is uninsured? Poor diets lead to poor health, and poor health without medical treatment is disastrous. That linkage needs more exploration.

Roy Mitchell, who directs the Mississippi Health Advocacy Program, told me, “Nobody has really talked about the underlying conditions of African Americans. To date there has not been an appreciable focus on health disparities and social determinants of health in Mississippi by policymakers.”

In Nebraska there hasn’t been much talk about that either, but there has been plenty of conversation about delaying implementation of Medicaid expansion the voters approved two years ago. Yet, says Sen. Machaela Cavanaugh, who represents a part of Omaha in the state legislature, “Everything about this plan is obstructionist. I’m not able to find good intentions in the plan. I have a small amount of confidence it will start in October, and it goes against the will and intent of the voters.” She called the delay an “abuse of power” that has been happening since April 2019, when the state began to craft its program.

About 70% of the state population eligible for expansion coverage is working but gets no insurance from their employers, says Molly McCleery, a health attorney at Nebraska Appleseed. Yet the state’s expansion calls for onerous work requirements in the second year of the program. If they are not met, recipients receive lesser coverage “Some policymakers get it,” McCleery says. “They understand that if you want workers to be in good health, taking away their health care doesn’t lead to those results. Other policymakers believe they need increased responsibility for this population.” And that ties in with the racism, the unspoken barrier to expansion. In 2018, 41% of Medicaid participants in Nebraska were white, 20% were black, and 30% were Hispanic.

Nebraska has designated two levels of coverage with different benefit packages. Under the basic plan, Nebraskans will receive basic Medicaid benefits, excluding such important coverage as dental and vision services and over-the-counter drugs.

As prime members, recipient gets the full benefit package if they satisfy seven requirements that would be unthinkable to most Americans with employer or Affordable Care Act health insurance. These include not missing three or more doctor appointments in a six-month period, selecting a primary care doctor, notifying the state within 10 days if there’s a change in status, and maintaining commercial health insurance, if available.

The state is also imposing work requirements under the waiver in the second year of the expansion, which present barriers that other insured Nebraskans do not have to hurdle. Medicaid recipients must work or volunteer for a public charity for at least 80 hours a month; enroll at least half time in an educational program; be a qualified caregiver or a foster parent; participate in certain government programs; or engage in certain job search activities for at least 20 hours per week. These requirements can be considered onerous in the extreme, given that most of the eligible population is already employed.

“Our approach better achieves the purpose of the Medicaid program by incentivizing positive activities that will improve health outcomes and encourage life successes for participants,” the Nebraska Department of Health and Human Services said in a news release.

Other states that have expanded have imposed similar work requirements, giving them an easy way to kick people off the rolls if someone fails to comply. The waiver in Utah, for example, requires those covered under the state’s expansion to conduct 48 job searches within the first three months of enrollment — an impossibility for all but the most dogged researcher. That requirement has been suspended because of the pandemic.

Work requirements in other states that have expanded Medicaid are tied up in the courts.

Nebraska estimates one-third of the people enrolled in the Medicaid expansion would not receive the full prime coverage and with it, coverage for dental, vision and over-the-counter drugs, which Medicaid policymakers seem to regard as inconsequential health care services. Amy Behnke, chief executive officer of the Health Center Association of Nebraska, told me that the seven federally qualified health centers in her association say dental care is a huge need. At one center in Gering, Nebraska, which serves 17 western and less populated counties, doctors see more patients for dental problems than for medical issues.

Jones argues that the way Medicaid expansion plays out in predominantly white states like Nebraska is also a function of racism. “The plurality of poor groups are white folks, but the idea politicians hold is that programs benefit people of color, and that’s why there’s not widespread support for them.”

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.

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THINKING ABOUT HEALTH

At the height of the pandemic, many Americans are experiencing firsthand the flaws in the Affordable Care Act and the health insurance it guaranteed. They are also facing the possibility that even the protection it does afford may be stripped away.

The fate of the Affordable Care Act (ACA), also known as Obamacare, is again uncertain. The 2010 law that began to whittle down the large number of uninsured Americans is back at the U.S. Supreme Court awaiting a decision – most likely next year – about whether it is constitutional. The court has upheld the law against court challenges twice before.

In late June the Justice Department filed a brief asking the court to overturn the Act. The Administration argued that the entire law is invalid because Congress eliminated the individual mandate in 2017, which had required almost all Americans to carry health insurance. Therefore, the ACA can no longer be considered a “tax,” which was the basis on which the court found it constitutional in 2012.

The Administration also argued that two other provisions make the law unconstitutional. One calls for insurance companies to sell coverage to people who have preexisting conditions, so-called guaranteed issue policies. The other requires community rating.

Community rating prevents insurers from varying premiums based on geography, age, and other factors. The Administration said in its legal brief that without those three provisions the Affordable Care Act cannot survive.

If the Court sides with the group of Republican attorneys general who brought the case and strikes down the law, that means the millions of Americans with preexisting health conditions will be in the same pickle they were in before the law took effect in 2013.

They will have trouble buying new insurance that covers medical conditions they already have since insurers would no longer be required to offer them coverage. People with common ailments like diabetes, heart disease, mental illness, and cancer would be out of luck once again. But so would people with more minor problems like recurrent ear or sinus infections.

A new group of Americans may also find it impossible to get coverage. Those who have recovered from COVID-19 may face long-lasting health challenges resulting from their illness.

Reports are coming in that detail such problems as blood clots, strokes, heart and lung damage, and neurological problems such as numbness and muscle weakness. It’s unlikely any insurance company would voluntarily issue coverage to people with those medical problems.

Like sick people before the Affordable Care Act took effect, COVID-19 survivors will be uninsured.

Do Americans really want to go back to the days when sick people, the very ones who need insurance coverage, are thrown out of the marketplace?

I would argue they don’t. The last four months have taught us that we are all vulnerable to the possibility of long-lasting medical harm from the coronavirus. Insurance to help cover whatever ills show up is essential.

The Affordable Care Act, however, was not a perfect solution for uninsured Americans. Millions of people who’ve had to turn to the ACA because they lost their employer-provided coverage during the pandemic shutdown are learning about its shortcomings, which were given short shrift for years by politicians and the media advocates for the law.

“With health insurance in particular we have a social support system that really isn’t very functional when you have job loss,” Ben Zipperer, an economist with the Economic Policy Institute in Washington, D.C., told Bloomberg News. That’s a problem in the best of times, he said, adding, “It’s a real disaster when you have tens of millions of workers suddenly lose their jobs.”

Some 27 million workers may have lost their job-based coverage as of the first of May.

Many of those newly uninsured have experienced the weaknesses that were baked into the law. Policies with cheaper premiums come with high deductibles, often $7,000 or $8,000 a year or more. Paying that much out of pocket is a heavy lift for those out of work.

The trade-off is paying higher premiums. That’s hard, too. Some people who’ve lost coverage might qualify for Medicaid, or they may qualify for subsidies under the ACA that help pay premiums or required cost sharing. Those are options people in that predicament should investigate, but many people won’t qualify.

If the ACA survives this latest challenge and everyone sick or well can still buy insurance, maybe the country can begin to make sure no American goes without coverage when another disaster strikes.

What improvements would you like to see in health insurance? Write to Trudy at trudy.lieberman@gmail.com.

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