Eligibility Waivers to Leave Many With Costs From COVID-19

One more reason, now that COVID is causing so much unemployment, that we desparately need Medicare for All, with no qualifications other than US citizenship. We can give corporations and wealthy people billions in tax breaks, but not one red cent for people’s health care in a nationwide, single payer system that would have responded rationally and logistically to a pandemic, instead of as a “chaotic disaster.”

Health Affairs Blog

May 8, 2020

Medicaid Retroactive Eligibility Waivers Will Leave Thousands Responsible For Coronavirus Treatment Costs

By Paul Shafer  Nicole Huberfeld  Ezra Golberstein

The coronavirus pandemic has led to record numbers of American workers being laid off or seeing their hours and paychecks dwindle. The economy is on the brink of a deep recession, and waves of coronavirus infections may continue for the foreseeable future. Medicaid will be a crucial piece of the puzzle that helps to ensure access to health care while protecting people from further financial ruin. Yet, one of Medicaid’s key provisions has been weakened by recently approved section 1115 “demonstration projects”, commonly referred to as waivers, that eliminate or reduce retroactive coverage. These waivers will diminish coverage for thousands of people seeking testing and treatment for COVID-19 and other medical care.

Retroactive eligibility is a long-standing feature of Medicaid that covers health care expenses for three months prior to the application date, provided that the beneficiary would have been eligible during that period. Before the Affordable Care Act (ACA), a handful of states imposed narrow restrictions on retroactive eligibility, but these limitations were paired with expansions of eligibility and had exemptions for vulnerable groups. Recently, however, many states—including Arizona, Arkansas, Florida, Indiana, Iowa, Kentucky, and New Hampshire—have gained Department of Health and Human Services (HHS) approval for 1115 waivers that drastically limit or completely eliminate retroactive eligibility, though four have been stayed by courts or halted by states as part of litigation challenging the legality of those waivers that include work requirements (Arkansas, Kentucky, Indiana, and New Hampshire).

A core purpose of Medicaid is supporting people when they need help, which is why Medicaid has continual open enrollment and retroactive eligibility to cover the cost of care when those who are eligible aren’t already enrolled before a crisis. States should restore full retroactive eligibility immediately to protect thousands of newly-unemployed workers from even greater health and economic suffering.

https://www.healthaffairs.org/do/10.1377/hblog20200506.111318/full/

The Sad Downside to Globalization: Economics Over Public Health In The Age of Covid-19

Tom Lynch of Workers’ Comp Insider posted the following yesterday about where most of the masks and other protective equipment worn by health care workers comes from, and in particular, one CEO’s experience with the beginning of a global pandemic.

Here is the article.

If you are wondering why there have been mass protests (mostly supported by, and instigated by, conservative groups and wealthy, libertarian right-wing families such as the DeVos, Dorr, and other families, and commentators such as Alex Jones and Fox News), it is because many of these people have been outsourced from jobs that were sent to China and elsewhere.

Some are just members of militia groups flexing their muscles, but thankfully, polls show more Americans support restrictions, rather than opening up the economy. Apparently, it is the economy of these families that are most affected by the shutdowns, and thus they are only interested in their economic interests, not public health.

Witness the statements of some GOP elected officials who stated that the economy was more important than living (Texas’ Attorney General, for one).

So, while Trump makes a clusterf**k of the response, let’s remember that we did not understand that there were consequences for shipping our manufacturing jobs to China, and COVID-19 is the result.

Richard’s note: The masks I use for my dialysis treatment come from China.

Mass Unemployment and COVID-19: What It Means for Health Insurance

Steffie Woolhandler, M.D. and David Himmelstein, M.D. wrote yesterday in the Annals of Internal Medicine that many of those who lose, or already lost their jobs due to the coronavirus pandemic have a lack of health insurance. Many did not have insurance before the outbreak, and now that they are unemployed, their employer-based insurance will end as well.

Here is the article in full:

Annals of Internal Medicine

April 7, 2020

Intersecting U.S. Epidemics: COVID-19 and Lack of Health Insurance

By Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD

During the final week of March 2020, the U.S. Department of Labor reported that a record number of workers—6.648 million—filed new claims for unemployment benefits. That beat the previous record of 3.307 million filings, which was set the week before, bringing the 2-week total to 9.955 million. This is just the beginning of the surge in joblessness due to the coronavirus disease 2019 (COVID-19) pandemic. A Federal Reserve Bank economist estimated that the ranks of unemployed persons will swell by 47.05 million by the end of June.

For many, job loss will carry the added sting of losing health insurance. Congress has moved to cover severe acute respiratory syndrome coronavirus 2 testing for uninsured persons, but did not include provisions to cover treatment of COVID-19 (or other illnesses). The recent $2 trillion bailout bill offered no new health insurance subsidies or coverage.

Estimating Coverage Losses

We estimated the likely effects of current job losses on the number of uninsured persons by using data from the U.S. Census Bureau’s March 2019 Current Population Survey on health insurance coverage rates among persons who lost or left a job. The uninsurance rate among unemployed persons who had lost or left a job was 26.3% versus 10.7% among those with jobs. Applying the 15.6–percentage point difference to the 9.955 million who filed new unemployment claims last week, we estimate that 1.553 million newly unemployed persons will lose health coverage. This figure excludes family members who will become uninsured because a breadwinner lost coverage and self-employed persons who may lose coverage because their businesses were shuttered, but are ineligible for unemployment benefits. If, as the Federal Reserve economist projects, an additional 47.05 million people become unemployed, 7.3 million workers (along with several million family members) are likely to join the ranks of the U.S. uninsured population.

Coverage losses are likely to be steepest in states that have turned down the Patient Protection and Affordable Care Act’s Medicaid expansion. In expansion states, the share of persons who have lost or left a job who lacked coverage was 22.1% versus 8.3% for employed persons—a difference of 13.8 percentage points. In nonexpansion states, the uninsurance rate among such unemployed persons was 38.4% versus 15.8% for employed persons—a difference of 22.6 percentage points. In other words, nearly 1 in 4 newly unemployed workers in nonexpansion states are likely to lose coverage, bringing their overall uninsurance rate to nearly 40%.

Our projections are based on differences in coverage rates for employed and unemployed persons in 2019, but there is little reason to believe that the predicament of unemployed workers has improved since then. Although many who lose their jobs are likely to be eligible for Medicaid or subsidized Affordable Care Act coverage, and some will purchase continuing coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act), the same was true in 2019. Indeed, the situation may be worse today because some laid-off workers probably gained coverage through an employed spouse in 2019, an option less likely to be available in the face of the impending massive layoffs.

Urgent Policy Needs and Longer-Term Solutions

With jobs and health insurance coverage disappearing as the COVID-19 pandemic rages, states that have declined to expand Medicaid should urgently reconsider. Yet, the high uninsurance rate among unemployed persons in Medicaid expansion states underlines the need for action in Washington. Tax revenues are plunging, and all states except Vermont are required to balance their budgets annually. Hence, only the federal government has the wherewithal to address the impending crisis.

Thus far, neither Congress nor the administration has offered plans to expand coverage. Some have suggested that the federal government cover COVID-19–related care for uninsured persons through Medicaid, but some states would probably decline such a Medicaid expansion, leaving many newly jobless persons—and the 28 million who were uninsured before the pandemic—without coverage. Instead, we advocate for passage of an emergency measure authorizing Medicare coverage for all persons eligible for unemployment benefits.

Although the COVID-19 crisis demands urgent action, it also exposes the imprudence of tying health insurance to employment, and the need for more thoroughgoing reform. A trickle of families facing the dual disaster of job loss and health insurance loss can remain under Washington’s radar. However, the current tsunami of job and coverage losses along with a heightened risk for severe illness demands action. A decade ago, Victor Fuchs forecasted that “National health insurance will probably come to the United States after a major change in the political climate—the kind of change that often accompanies a war, a depression, or large-scale civil unrest.” Such a major change may be upon us.

https://annals.org/aim/fullarticle/2764415/intersecting-u-s-epidemics-covid-19-lack-health-insurance

Another Reason for Medicare for All

While all of you are working from home, perhaps you can consider what Marcia Angell says below in between doing your work and playing with the kids.

Santa Fe New Mexican

March 21, 2020

Why the U.S. failed the coronavirus test

By Marcia Angell

The coronavirus pandemic is the best argument for “Medicare for All.” As it stands, most Americans get health care only if we have insurance that will pay for it. If we don’t or we can’t afford the deductibles and copayments, too bad. Every other advanced country provides universal health care in a predominately nonprofit system.

What happens, then, when Americans develop a fever and cough? Are they likely to seek medical help, despite the hefty bills they are sure to receive, particularly if, say, the radiologist is out of network or the insurance company refuses to pay for some other reason? The new coronavirus, while highly contagious, is usually mild, so people with minimal symptoms might simply take their usual cold remedies while they go about their business and spread the infection widely.

The problem is that we treat health care like a market commodity distributed according to the ability to pay in an uncoordinated system with hundreds of commercial insurers and profit-oriented providers. Some 30 million people have no access to health care because they are uninsured, and millions more don’t use their insurance because the deductibles and copayments are unaffordable. In addition, insurers usually require patients to get their care within a narrow network of providers and exclude certain services.

The shortage of test kits for coronavirus stems from a related problem. Since there was no commercial market for them, they didn’t get made immediately. While we’ve converted health care into a market commodity, we’ve hollowed out our public health system, so it couldn’t do the job.

For all we know, the coronavirus may already have spread widely within the United States. Although it has been in other countries for more than two months, we have not really looked for it here. Until the last week in February, our premier public health agency, the Centers for Disease Control and Prevention, limited its diagnostic testing to symptomatic patients who had traveled to China or had contact with someone known to be infected. This is akin to looking for lost keys only under a lamppost.

The CDC probably could not have done better, given its lack of funding and governmental support. But ignorance is hardly a good public health strategy. Right from the beginning, we should have made test kits available to state and local public health agencies (as was done in Italy and South Korea). The only way to deal with an epidemic of this scope is with a universal health care system like “Medicare for All” and a strong, well-funded public health network.

The political opposition to “Medicare for All” is puzzling, since Medicare is the most popular part of our current fragmented system. In fact, many 64-year-olds can hardly wait to be 65, so they will be eligible. Why, then, do opponents of “Medicare for All” seem to believe that extending this popular program to everyone would be a sacrifice? Would a 64-year-old really prefer private insurance, with its networks and variable benefits, to Medicare, with its free choice of doctors and guaranteed benefits?

It’s true that taxes would have to increase to pay for “Medicare for All,” but the taxes could be as progressive as we wanted. For most Americans, they would probably be completely offset by the elimination of premiums, deductibles and copayments. In addition, the system as a whole would be far more efficient, because of the reduction in our gigantic overhead costs and the elimination of most profits. Most important, cost inflation would slow greatly, so that in a few years we would come out well ahead.

But as important as cost control is, my reason for favoring “Medicare for All” is primarily moral. Health care is not like ordinary consumer goods that people can choose to purchase. Illness is not a choice; it’s a misfortune. So why should people have to pay for it, as if they wanted it? Providing health care, just like providing clean water or police protection or basic education, is simply what decent societies should do. And during an epidemic, it protects all of us. The coronavirus pandemic powerfully underscores the need for a coherent national health system, in which we all pull together.

Marcia Angell is a member of Harvard Medical School’s Department of Global Health and Social Medicine, and a former editor-in-chief of the New England Journal of Medicine. She will soon be a resident of Santa Fe.

https://www.santafenewmexican.com/opinion/my_view/why-the-u-s-failed-the-coronavirus-test/article_cb92b8a6-694c-11ea-80b4-078d871fd2e9.html

If Not Now, When?

Don McCanne posted the following article from Health Affairs by Adam Gaffney, President of Physicians for a National Health Plan (PNHP). The full text and exhibits can be found at the link at the bottom.

Health Affairs Blog

March 9, 2020

Medicare For All: If Not Now, When?

By Adam Gaffney

The rise of Medicare for All has triggered mixed reactions.  Supporters see it as a cause for hope — the culmination of decades of research, education, and advocacy.  President Donald Trump, on the other hand, is dyspeptic, fuming in his recent State of the Union that single-payer would “bankrupt our nation,” and vowing not to “let socialism destroy American healthcare.”  A third group expresses sympathy for the goals of Medicare for All, and even acknowledges its policy merits, but sees the political obstacles as insurmountable — and advises that advocacy for such reform should be abandoned because it risks undermining beneficial, and more realistic approaches.

A clear-eyed assessment of institutional realities that will face the next presidential administration, Billy Wynn recently argued in the Health Affairs blog, should temper Democrats’ demands. He cautioned that Democratic victories in federal elections are far from secure; that Medicare for All may not be passable via budget reconciliation even if Democrats take the Senate with only a simple majority; and that Democratic legislators are, in any event, hardly unified in support of Medicare for All.  Similarly, John E. McDonough recently warned that comprehensive healthcare reform has, in the past, required an elusive “super-majority Trifecta” — Democratic control of the House, Senate (with 60-seats), and Presidency.  Even under such favorable conditions, he contends, our political capital might be better invested elsewhere.

While the hurdles are certainly formidable, steep political odds hardly compel us to abandon Medicare for All.  Indeed, advice to drop the push for such reform rests on a misunderstanding of the dynamics of political change.  History suggests that movements organized around ambitious demands can, over time, create the conditions for their passage — and that demands for radical change often advance, rather than undermine, the prospects for more incremental progress in the interim.  As important, the life-and-death urgency of single-payer healthcare reform – too often underemphasized by its critics – has the potential to bring together a coalition of supporters across cultural, geographic and even class lines.  It may, in other words, trigger a movement that could accomplish the unexpected.

The Dynamics of Political Change: Lessons from History

The institutional barriers that critics describe are real enough, and cannot be waved away.  But they are also not immutable: throughout history, energizing issues have changed political contexts.

Consider, for instance, the passage of Medicare and Medicaid in 1965.  Democrats had been stymied since the Truman administration in their efforts to pass a public national health insurance plan, obstructed in part by members of Congress intent on accommodating the insurance industry. John McDonough is right to emphasize that, from a narrow perspective, a super-majority Trifecta made Medicare achievable.  1964 saw a historic electoral shift, that, as Ted Marmor has noted, all but “guaranteed the passage of legislation on medical care for the aged.”  But the achievement was only possible because people had been laying the groundwork for Medicare for years prior to the pivotal election.  Senior citizen groups, progressive activists, organized labor, and allies in the civil rights movement forced it onto the national political agenda, holding politicians feet to the fire year after year — a point made by Natalie Shure in the Nation.  Moreover, it required years of legislative efforts and coalition building to ready the ground for the final push. Had supporters not done so — had everyone waited to design and advocate for Medicare until the political chess pieces were in perfect position — the window would have opened, the window would have closed, and Medicare might very well not have come to be.

The same can be said for almost every sweeping political change in US history. The abolition of slavery, the reforms of the New Deal era, the civil rights legislation of the 1960s, and the legalization of gay marriage — none would have happened if reformers had patiently waited for the proper political alignment in the halls of Congress before envisioning, designing, and demanding change.  The 2020 elections may or may not cause a political earthquake on par with 1964, but it hardly follows from this that we ought to lower our sights.  After all, nobody can accurately predict when the pivotal shift will come.  We do know, however, that if we wait for it happen, we will already be too late.

The Urgency of National Health Insurance

(Use the link below to access this important section of the article.)

Medicare for All — unlike other reforms — would alleviate such widespread and unnecessary suffering not merely by covering the uninsured, but by eliminating financial barriers to care.  Rising costs from higher care utilization will be offset by large savings from simplifying administration. Indeed, a recent systematic review found that some 19 out of 22 economic analyses of Medicare for All predicted overall savings in the first year as a result of such efficiencies.  Transforming healthcare financing is what makes such an unprecedented coverage expansion economically— and hence politically — feasible.

The policy advantages of Medicare for All, in other words, aren’t mere minutiae: they are part of the force for political change.

Medicare for All: The Link Between Policy and Politics

Yet policy and politics are linked in another, more fundamental way.  The experience of illness and of medical care is almost universal.  This means that in the United States, encounters with our dysfunctional healthcare financing system are also near universal.  How many have never had a spell of being uninsured, dealt with an onerous copay or deductible, contended with a medical bill or collections agency, gone without needed care because of cost, or faced a denial of care from their insurer?  It is not merely uninsured Americans who have much to gain from single-payer reform, but also those with chronic conditions who pay a tax for their illness in the form of cost-sharing; those with Medicare coverage who lack dental and long-term care benefits; those with Medicaid who must hurdle administrative barriers to remain covered and face frequent “churn” out of the program, and who sometimes have inferior access to care.  Indeed, even those satisfied with their employer-sponsored coverage know that they are but one sickness — and consequent job loss — away from losing it.

All of which is to say that at the end of the day, the vast majority of the nation could benefit from single-payer reform — and that fact makes it winnable.  Above all, however, we can be sure of one thing: not bothering to push for Medicare for All today will guarantee that it doesn’t happen tomorrow.

The author serves as President of Physicians for a National Health Program (PNHP), a non-profit organization that favors coverage expansion through a single payer program.

https://www.healthaffairs.org/do/10.1377/hblog20200309.156440/full/

Job Churn Benefit of Medicare for All

For those who believe that MFA would be a job killer, here is an article from the Economic Policy Institute that dispeals that belief.

Economic Policy Institute

March 5, 2020

Fundamental health reform like ‘Medicare for All’ would help the labor market

Job loss claims are misleading, and substantial boosts to job quality are often overlooked

By Josh Bivens

Fundamental health reform like “Medicare for All” would be a hugely ambitious policy undertaking with profound effects on the economy and the economic security of households in America. But despite oft-repeated claims of large-scale job losses, a national program that would guarantee health insurance for every American would not profoundly affect the total number of jobs in the U.S. economy. In fact, such reform could boost wages and jobs and lead to more efficient labor markets that better match jobs and workers. Specifically, it could:

*  Boost wages and salaries by allowing employers to redirect money they are spending on health care costs to their workers’ wages.

*  Increase job quality by ensuring that every job now comes bundled with a guarantee of health care—with the boost to job quality even greater among women workers, who are less likely to have employer-sponsored health care.

*  Lessen the stress and economic shock of losing a job or moving between jobs by eliminating the loss of health care that now accompanies job losses and transitions.

*  Support self-employment and small business development—which is currently super low in the U.S. relative to other rich countries—by eliminating the daunting loss of/cost of health care from startup costs.

*  Inject new dynamism and adaptability into the overall economy by reducing “job lock”—with workers going where their skills and preferences best fit the job, not just to workplaces (usually large ones) that have affordable health plans.

*  Produce a net increase in jobs as public spending boosts aggregate demand, with job losses in health insurance and billing administration being outweighed by job gains in provision of health care, including the expansion of long-term care.

The upshot: M4A creates a small amount of manageable churn but increases the overall demand for labor and boosts job quality

The job challenge relating to a fundamental health reform is managing a relatively small increase in job churn during an initial phase-in period. Most Medicare for All plans explicitly recognize and account for the costs of providing these workers the elements of a just transition. This sort of just transition is far easier when health care is universally provided.

Besides this challenge, the effect of fundamental reform like M4A on the labor market would be nearly uniformly positive. The effect of a fundamental reform like M4A on aggregate demand is almost certainly positive and will therefore boost the demand for labor. The number of jobs spurred by increased demand for new health care spending (including long-term care) will certainly be larger than the number displaced by realizing efficiencies in the health insurance and billing administration sectors.

Finally, the introduction of fundamental health reform like M4A—particularly reform that substantially delinks health care provision from specific jobs—would greatly aid how the labor market functions for typical working Americans. Take-home cash pay would increase, job quality would improve, labor market transitions could be eased for employers and made less damaging to workers, and a greater range of job opportunities could be considered by workers. The increased flexibility to leave jobs should lead to more productive “matches” between workers and employers, and small businesses and self-employment could increase.

Fundamental health reform would benefit typical American families in all sorts of ways. Importantly, contrary to claims that such reform might be bad for jobs, this reform could substantially improve how labor markets function for these families.

https://www.epi.org/publication/medicare-for-all-would-help-the-labor-market/

Full report (13 page PDF):

https://www.epi.org/files/pdf/186856.pdf

Moderate Democrats Health Care Plans Fall Short

Listening to the Democratic debates since they began last year, I have been dumbfounded and angered that so many of the candidates running for President this year believe that some halfway measure to achieve universal coverage for health care is possible, if only voters would vote for them.

With the exception of Bernie Sanders and Elizabeth Warren, the rest of the candidates, those still running, and those who dropped out, advocate a public option or fixing the ACA. (see “Medicare for All and the Democratic Debates”) Their proposals fly in the face of study after study, article after article that firmly states that the only way to provide universal coverage at lower cost, and that will save money is Medicare for All.

They are trying to scare the American people with words like “Socialism” and suggesting that their taxes will go up, or that they will lose their employer-based or private health insurance.

As I have written in the past, there is a concerted effort on the part of the health care industry to defeat Medicare for All/Single Payer, and they have been targeting the Democrats to do so.

An article last Monday in The Hill by Diane Archer, senior adviser at Social Security Works states that twenty-two studies agree that Medicare for All saves money.

According to Ms. Archer, researchers at three University of California campuses examined 22 studies on the projected cost impact for single-payer health insurance in the United States and reported their findings in a recent paper in PLOS Medicine.

Every single study, they found, predicted that it would yield net savings over several years. In fact, it’s the only way to rein in health care spending significantly in the U.S.

In addition, all of the studies, regardless of ideological orientation, showed that long-term cost savings were likely. As reported last year, even the Mercatus Center, a right-wing think tank belonging to the libertarian Koch Brothers, recently found about $2 trillion in net savings over 10 years from a single-payer Medicare for All system. Most importantly, everyone in America would have high-quality health care coverage

The key takeaway from the studies is that Medicare for All is far less costly than our current system largely because it reduces administrative costs.

This is because Administrative savings from Medicare for All would be about $600 billion a year. Savings on prescription drugs would be between $200 billion and $300 billion a year, if we paid about the same price as other wealthy countries pay for their drugs. A Medicare for All system would save still more with implementation of global health care spending budgets.

None of the other Democratic candidates can make that assertion because their plans leave many uninsured and and keep in place the insurance companies and pharmaceutical companies to make huge profits from the health of the American people.

While I am no fan of Bernie Sanders as a candidate, and his recent dispute with the Nevada Culinary Union not withstanding, his goal is to cover every American with universal health care. Elizabeth Warren’s plan differs somewhat from Sanders’, but has a more reasonable time frame for implementation.

The inconvenient truth, folks is that Medicare for All will save money, will cover everyone, and will finally bring down the cost of health care so that no one has to go broke paying for it, or decide not to get medical care when needed because they can’t afford it.’

Those of you who are not physicians or in the insurance industry, or the pharmaceutical industry who pontificate on social media that Medicare for All is bad, are only delaying the inevitable. You consultants, analysts, researchers and other auxiliary industries to health care must see the truth staring you in the face. You are on the wrong side of the debate, and on the wrong side of history.