Newsom's 2021-22 fiscal year spending plan does not include additional public health money for local health departments steering California's pandemic response.
This article was published on Tuesday, January 12, 2021 in Kaiser Health News.
SACRAMENTO, Calif. — The coronavirus pandemic doomed Gov. Gavin Newsom's ambitious plans last year to combat homelessness, expand behavioral health services and create a state agency to control soaring healthcare costs.
But even as the pandemic continues to rage, California's Democratic governor said Friday he plans to push forward with those goals in the coming year, due to a rosier budget forecast buoyed by higher tax revenue from wealthy Californians who have fared relatively well during the crisis.
Newsom's $227.2 billion budget blueprint also prioritizes billions to safely reopen K-12 schools shuttered by the pandemic, $600 payments for nearly 4 million low-income Californians — in addition to federal stimulus payments — and coronavirus relief grants and tax credits for hard-hit small businesses.
However, his 2021-22 fiscal year spending plan does not include additional public health money for local health departments steering California's pandemic response, which have been chronically underfunded. He vowed to support cities and counties by boosting state testing and contact tracing capacity, speeding vaccination efforts and funding state-run surge hospitals that take overflow patients.
Newsom said Friday his budget reflects a "pandemic-induced reality" with investments aimed at spurring California's economic recovery by helping businesses and people living in poverty. Wealth and income disparities, he added, "must be addressed."
But Democrats in control of the state legislature, county leaders and social justice groups say that will be difficult to achieve because Newsom's spending plan does not sufficiently fund health and social safety-net programs.
And without additional public health money, local leaders worry California will not be able to adequately control the spread of the virus.
"County public health is drowning," said Graham Knaus, executive director of the California State Association of Counties. "We are triaging right now between testing, contact tracing and vaccination, and it's impacting the response to the pandemic."
Newsom's budget proposal is the first step in a months-long negotiation process with the Democratic-controlled legislature, which has until June 15 to adopt the state budget that takes effect July 1. Lawmakers have become increasingly frustrated with the governor's response to the pandemic, including his unilateral spending decisions in response to the emergency. Newsom is also facing a burgeoning recall effort, backed by heavyweight Republicans such as former San Diego Mayor Kevin Faulconer, who is considering challenging Newsom in the 2022 California gubernatorial election.
Newsom said he expects to make some tough calls on spending even though the state anticipates a $15 billion budget surplus for the coming fiscal year, largely because a state fiscal analysis projected deficits in subsequent years.
"While we are enjoying the fruits of a lot of one-time energy and surplus, it's not permanent and we have to be mindful of over-committing," Newsom said, explaining why he didn't include funding to expand Medicaid to more unauthorized immigrants.
Some lawmakers say they will nonetheless press Newsom to use higher-than-expected revenues — and perhaps seek new taxes — to expand health coverage to more Californians.
The following healthcare proposals factor heavily into Newsom's 2021-22 budget proposal.
Covid Relief
Newsom committed $4.4 billion in his budget to vaccine distribution, increased testing, contact tracing and other short-term pandemic expenses. Because that spending is related to the public health emergency, the state expects at least 75% to be reimbursed by the federal government and insurance payments.
He also proposed $52 million to fund costs at state-run surge hospitals, including support staff. And he is asking lawmakers to sign off on a covid relief package that would provide funding before the start of the fiscal year in July. It would include $2 billion to help school districts reopen classrooms to in-person instruction beginning in February by paying for protective equipment, ventilation systems and adequate testing. It would also commit billions to economic recovery, such as stimulus payments for individuals, and grants and tax credits for struggling small businesses.
Newsom also wants to increase the budget for the Department of Industrial Relations by $23 million to fund up to 113 additional workplace inspectors at the California Division of Occupational Safety and Health to police health order violations at businesses and enforce workplace safety laws.
Transforming Medi-Cal
Spending for Medi-Cal, the state's Medicaid program for low-income residents, is expected to grow in the coming year because of the economic impact of the pandemic — as is its enrollment. The program has roughly 13 million enrollees, or about one-third of the state population.
In the coming year, Newsom will also press forward with a major overhaul of Medi-Cal, through a project called CalAIM, to provide new benefits emphasizing mental healthcare and substance use treatment, and pay for some nontraditional costs such as housing assistance. The hope is the program would divert homeless and other vulnerable people away from expensive emergency room care and keep them out of jail.
State Medi-Cal officials estimate the program would cost $1.1 billion for the first year. The state is working with the federal Centers for Medicare & Medicaid Services to obtain approval for the program.
Newsom also wants to expand Medi-Cal benefits to cover over-the-counter cold medicine and blood glucose monitors for people with diabetes. His budget includes $95 million for a major expansion of telehealth services that would permanently provide higher payments for virtual doctor visits.
Controlling Healthcare Costs
Newsom is proposing a new state agency, the Office of Healthcare Affordability, which he said would help control healthcare costs. He budgeted $63 million over the next three years for the office, which would set healthcare cost targets for the healthcare industry — along with financial penalties for failing to meet future targets.
Powerful health industry groups said they are still assessing whether they will support the proposal. But some expressed concern last year when Newsom floated the idea. Doctors and hospitals routinely fight proposals in Sacramento that might limit their revenue.
Newsom acknowledged Friday the task would be "tough."
Battling Homelessness and Food Insecurity
Newsom is proposing a one-time infusion of $1.75 billion to battle homelessness.
Of that, Newsom said, $750 million would help counties purchase hotels and transform them into permanent housing for chronically homeless people. Another $750 million would allow counties to purchase facilities to treat people with mental illness or substance use disorders. And $250 million would help counties purchase and renovate homes for low-income older people.
Newsom's budget also includes $30 million to help overwhelmed food banks and emergency food assistance programs.
Lawmakers said they plan to negotiate for even more funding for homelessness and safety-net programs.
"We absolutely need to significantly increase our investment to address homelessness because the need is so intense," said Assembly member David Chiu (D-San Francisco). "And I don't think there's a single legislator who isn't incredibly concerned about the food insecurity we're seeing: lines around the block for food banks in what should be the wealthiest state in the country."
Expanding Health Coverage
Newsom did not include money in his proposed budget to expand Medi-Cal to unauthorized immigrants age 65 and older. He had previously promised to fund the proposal, estimated to cost $350 million per year once fully implemented, but he said Friday the state cannot afford to commit to ongoing costs with a projected budget deficit starting in fiscal year 2022-23. California already offers full Medicaid benefits for income-eligible unauthorized immigrants up to age 26.
Some lawmakers and healthcare advocates countered that providing health insurance for undocumented immigrants would save lives and reduce costs, especially during the pandemic, and vowed to continue to fight for the expansion.
"To say we are disappointed is describing it very lightly," said Orville Thomas, a lobbyist with the California Immigrant Policy Center. "These are Californians dying and getting sick at disproportionate rates during covid."
Illinois and Chicago officials are trying to figure out how to stop a private company from closing a money-losing urban hospital in a poor, underserved Chicago neighborhood.
Trinity Health, a national Catholic tax-exempt chain, wants to close Mercy Hospital and Medical Center on Chicago's Near South Side by May 31. Last month, in an unusual move, the Illinois Health Facilities & Services Review Board unanimously denied Trinity permission to close the 412-bed facility, which predominantly serves Black and other minority patients on Medicaid.
The board members said they feared the closure would limit access to care for nearly 60,000 South Side residents, forcing them to travel nearly 7 miles to the closest facility with an emergency room, intensive care unit and birthing center. It also would cost the community about 2,000 hospital jobs.
So far, no one has come up with a politically and financially viable solution for strengthening safety-net health providers in low-income urban communities. "The sad fact is market location is everything," said Lawton Robert Burns, a professor of healthcare management at the University of Pennsylvania, who studied the controversial closure of Hahnemann University Hospital in Philadelphia in 2019. "No offense to poor people, but there are economic factors that hospitals can't control."
But it is far from clear that a government board can stop a hospital from going out of business. "It's really difficult in a capitalist country to tell a private company you have to continue to lose money," said Dr. Linda Rae Murray, a member of the health facilities board and former Trinity Health board member who teaches health policy at the University of Illinois-Chicago.
Trinity, which operates 92 hospitals in 22 states, seems determined to push forward with its plans to close the hospital. It has deep pockets, with $31.9 billion in total assets. It reported revenue of $18.8 billion last year, and a profit of 2.3% in the most recent quarter. Trinity executives told the health facilities board in December that Mercy loses nearly $39 million a year and that they could not find any buyers for the hospital — Chicago's oldest, chartered in 1852. They also reminded the board that state lawmakers rejected Mercy's 2019 $1 billion proposal to merge with three other South Side hospitals and build a new hospital facility and several new clinics with $520 million in state aid.
Trinity declined to make anyone available for an interview for this article.
Trinity has said it will try again to get approval to shut Mercy at the facilities review board's Jan. 26 meeting. It has offered to replace the hospital with a $13 million clinic offering just diagnostic and urgent care — but no primary care physician services. Critics of that proposal say the clinic, while helpful, would not be an adequate replacement for the hospital because it would not provide access to the full range of needed services.
"We can't have these mega-hospital companies that are getting a property tax exemption for providing charity care closing a safety-net hospital in the middle of a pandemic," said former Illinois Gov. Pat Quinn, a Democrat who spearheaded a 2013 deal to save Roseland Hospital, another embattled facility on Chicago's South Side. "I'd tell the Trinity executives, 'You're not doing this to Chicago. We'll work with you to put together a bigger deal.'"
The obvious long-term solution is richer Medicaid funding for safety-net hospitals, effective partnerships between public and private providers and firm commitments by financially strong hospital companies, including academic medical centers, to expand services in low-income communities. For instance, some say state and local officials should prod Trinity to use the resources of its Loyola University Medical Center in west suburban Chicago to bolster Mercy.
Hospitals are required to get a certificate of need for closure from the facilities review board, according to a new state law. But state officials' actions are limited when seeking to enforce a decision to keep a facility open.
The state could levy a fine of up to $10,000 for not complying with the board's decision, plus an additional $10,000 a month while the hospital continues to operate. But that's a trivial amount for a big company like Trinity.
The state also could halt Medicaid and other public payments to Mercy. But that would be counterproductive, hastening the hospital's demise since nearly half of Mercy's inpatient revenue and 35% of its outpatient revenue comes from Medicaid, according to state data.
A final source of leverage is in Trinity's ownership of three other hospitals in the Chicago area: Loyola, Gottlieb Memorial Hospital and MacNeal Hospital. The state could threaten Trinity's property-tax exemption as a charitable organization. That's an approach favored by Quinn, who cited a previous legal challenge to the tax-exempt status of the Carle Foundation Hospital in Urbana, Illinois.
No matter what the state does, Trinity can find ways to shut down Mercy. It could argue that even as Mercy is meeting the state requirement to continue to treat patients, it must close critical services like the emergency department or the birthing center because it lacks funding or staff to maintain adequate quality of care, said Juan Morado Jr., a Chicago healthcare lawyer who formerly served as general counsel for the facilities review board. The new law permits closing only one hospital department every six months.
While the state presses to keep the hospital open, Mercy also could suffer from attrition. When there's talk of closing a hospital, physicians, nurses and other staffers may start leaving for other jobs. Whether Trinity seeks to refill positions is critical.
"There are things the owner can do to trickle the hospital down to nothing," said Dr. David Ansell, senior vice president for community health equity at Rush University Medical Center in Chicago, who opposes shuttering Mercy. "There is a drip, drip, drip of negativity, and at some point people vote with their feet."
The Chicago area has been through a similar battle recently. Pipeline Health, a private-equity investment firm, bought Westlake Hospital in suburban Melrose Park and two other local hospitals from hospital chain Tenet Healthcare in 2019. Pipeline quickly announced it was closing Westlake, a 230-bed hospital — even though it had promised the state it would keep it open for at least two years.
That controversial move prompted the Illinois legislature to give the facilities review board new authority to deny permission for future hospital closures, which the board lacked for Westlake.
Yet, the Westlake saga may point to a better solution for Mercy. In early 2020, the state and federal governments renovated the Westlake facility so it could be used as an overflow site for covid-19 patients. It wasn't needed, but the updates led to strong interest from companies in purchasing and reopening the hospital, particularly for behavioral health inpatient services.
State Rep. Kathleen Willis, a Democrat who co-sponsored the 2019 bill to let the facilities review board say no to hospital closures, said a deal to buy and reopen Westlake likely will be announced within the next few weeks.
Any deal to save Mercy likely will require more money from Trinity, more commitment from other providers to offer a full range of hospital and medical services in the area, and significant increases in state and federal funding.
"Every hospital CEO has to worry about the bottom line of their business," Ansell said. "But big organizations like Trinity need to come up with a better solution than the wholesale shutdown of an anchor institution that will leave communities bereft."
Second Story is what is known as a "peer respite," a welcoming place where people can stay when they're experiencing or nearing a mental health crisis.
This article was published on Monday, January 11, 2021 in Kaiser Health News.
Mia McDermott is no stranger to isolation. Abandoned as an infant in China, she lived in an orphanage until a family in California adopted her as a toddler. She spent her adolescence in boarding schools and early adult years in and out of psychiatric hospitals, where she underwent treatment for bipolar disorder, anxiety and anorexia.
The pandemic left McDermott feeling especially lonely. She restricted social interactions because her fatty liver disease put her at greater risk of complications should she contract covid-19. The 26-year-old Santa Cruz resident stopped regularly eating and taking her psychiatric medications, and contemplated suicide.
When McDermott's thoughts grew increasingly dark in June, she checked into Second Story, a mental health program based in a home not far from her own, where she finds nonclinical support in a peaceful environment from people who have faced similar challenges.
Second Story is what is known as a "peer respite," a welcoming place where people can stay when they're experiencing or nearing a mental health crisis. Betting that a low-key wellness approach, coupled with empathy from people who have "been there," can help people in distress recover, this unorthodox strategy has gained popularity in recent years as the nation grapples with a severe shortage of psychiatric beds that has been exacerbated by the pandemic.
Peer respites allow guests to avoid psychiatric hospitalization and emergency department visits. They now operate in at least 14 states. California has five, in the San Francisco Bay Area and Los Angeles County.
"When things are really tough and you need extra support but you don't need hospitalization, where's that middle ground?" asked Keris Myrick, founder of Hacienda of Hope, a peer respite in Long Beach, California.
People with serious mental illness are more likely to experience emotional distress in the pandemic than the general population, said Dr. Benjamin Druss, a psychiatrist and professor at Emory University's public health school, elaborating that they tend to have smaller social networks and more medical problems.
That was the case with McDermott. "I don't have a full-on relationship with my family. My friends are my family," she said. She yearned to "give them a hug, see their smile or stand close and take a selfie."
The next best thing was Second Story, located in a pewter-gray split-level, five-bedroom house in Aptos, a quaint beach community near McDermott's Santa Cruz home.
Peer respites offer people in distress short-term (usually up to two weeks), round-the-clock emotional support from peers — people who have experienced mental health conditions and are trained and often certified by states to support others with similar issues — and activities like arts, meditation and support groups.
"You can't tell who's the guest and who's the staff. We don't wear uniforms or badges," said Angelica Garcia-Guerrero, associate director of Hacienda of Hope's parent organization.
Peer respites are free for guests but rarely covered by insurance. States and counties typically pick up the tab. Hacienda of Hope's $900,000 annual operating costs are covered by Los Angeles County through the Mental Health Services Act, a policy that directs proceeds from a statewide tax on people who earn more than $1 million annually to behavioral health programs.
In September, California Gov. Gavin Newsom signed a bill that would establish a statewide certification process for mental health peer providers by July 2022.
For now, however, peer respite staff members in California are not licensed or certified. Peer respites typically don't offer clinical care or dispense psychiatric drugs, though guests can bring theirs. Peers share personal stories with guests but avoid labeling them with diagnoses. Guests must come — and can leave — voluntarily. Some respites have few restrictions on who can stay; others don't allow guests who express suicidal thoughts or are homeless.
Peer respite is one of several types of programs that divert people facing behavioral health crises from the hospital, but the only one without clinical involvement, said Travis Atkinson, a consultant at TBD Solutions, a behavioral healthcare company. The first peer respites arose around 2000, said Laysha Ostrow, CEO of Live & Learn, which conducts behavioral health research.
The approach seems to be expanding. Live & Learn counts 33 peer respites today in the U.S., up from 19 six years ago. All are overseen and staffed by people with histories of psychiatric disorders. About a dozen other programs employ a mix of peers and laypeople who don't have psychiatric diagnoses, or aren't peer-led, Atkinson said.
Though she had stayed at Second Story several times over the past five years, McDermott hesitated to return during the pandemic. However, she felt reassured after learning that guests were required to wear a mask in common areas and get a covid test before their stay. To ensure physical distancing, the respite reduced capacity from six to five guests at a time.
During her two-week stay, McDermott played with the respite's two cats and piano — activities she found therapeutic. But most helpful was talking to peers in a way she couldn't with her mental health providers, she said. In the past, McDermott said, she had been involuntarily admitted to a psychiatric hospital after she expressed suicidal thoughts. When she shared similar sentiments with Second Story peers, they offered to talk, or call the hospital if she wanted.
"They were willing to listen," she said. "But they're not forceful about helping."
By the end of the visit, McDermott said that she felt understood and her loneliness and suicidal feelings had waned. She started eating and taking her medications more consistently, she said.
Financial struggles and opposition from neighbors have hindered the growth of respites, however. Live & Learn said that although five peer respites have been created since 2018, at least two others closed because of budget cuts.
Neighbors have challenged nearby respite placements in a few instances. Santa Cruz-area media outlets reported in 2019 that Second Story neighbors had voiced safety concerns with the respite. Neighbor Tony Crane told California Healthline that guests have used drugs and consumed alcohol in the neighborhood, and he worried that peers are not licensed or certified to support people in crisis. He felt it was too risky to let his children ride their bikes near the respite when they were younger.
In a written response, Monica Martinez, whose organization runs Second Story, said neighbors often target community mental health programs because of concerns that "come from misconceptions and stigma surrounding those seeking mental health support."
Many respites are struggling with increased demand and decreased availability during the pandemic. Sherry Jenkins Tucker, executive director of Georgia Mental Health Consumer Network, said its four respites have had to reduce capacity to enable physical distancing, despite increased demand for services. Other respites have temporarily suspended stays because of the pandemic.
McDermott said her mental health had improved since staying at Second Story in June, but she still struggles with isolation amid the pandemic. "Holidays are hard for me," said McDermott, who returned to Second Story in November. "I really wanted to be able to have Thanksgiving with people."
Keely Connolly thought she would be safe once the ambulance arrived at Hutchinson Regional Medical Center in Kansas.
She was having difficulty breathing because she'd had to miss a kidney dialysis treatment a few days earlier for lack of child care. Her potassium was dangerously high, putting her at risk of a heart attack. But she trusted she would be fine once she was admitted and dialysis was begun.
She panicked when a nurse told her that no beds were available and that she would have to be transferred — possibly more than 450 miles away to Denver. She had heard a rumor about a dialysis patient who died waiting for a bed at a hospital in Wichita, about an hour down the road.
"'I don't want to die in the ER,'" Connolly, 32, recalled thinking. "I just wanted them to fix me, but then the woman came in and said, 'There are no beds.' I got really scared and I didn't know if they had time to get me anywhere else."
When a bed was finally located 65 miles away in Salina, Connolly, who has kidney failure, was relieved but worried: How long would she be gone? Who would care for her young daughter? How would she get home? What would it all cost?
Connolly was caught in a situation experts have warned about since the beginning of the coronavirus pandemic: Covid-19 patients are overwhelming hospitals, squeezing space and staff needed to treat emergencies like Connolly's.
"This is the first time since I have been here that we've had a scenario where multiple hospitals, for longer periods of time, are experiencing some kind of shortages," said Cindy Samuelson, a senior vice president of the Kansas Hospital Association.
And it got worse after Connolly's emergency in mid-November. The 14-day rolling average positive test rate in Reno County, where Hutchinson is the county seat, reached 46% on Dec. 22, though it has since come down to 24% as of Jan. 4, said D.J. Gering, data analyst for the Reno County Health Department. The results did not include inmates from the Hutchinson Correctional Center, the local state prison.
By Oct. 1, four covid deaths had been recorded in the county of about 62,000. By Jan. 4, the death toll since the pandemic began had jumped to 105. For comparison, Gering said, Reno County had 19 deaths attributed to pneumonia and influenza combined in all of 2019.
Hospitalizations at the 190-licensed-bed Hutchinson Regional Medical Center increased 800% from mid-October to mid-December then started to temper at the end of the month, said Chuck Welch, vice president of Hutchinson Regional Medical System.
"I hate to be overly optimistic until we are well past the possible holiday surge from Christmas and New Year's," he said in an email.
Operating between 90% and 95% capacity, the hospital is providing care to patients with a multitude of needs and still has room to expand. The problem, Welch said, has been staffing.
Competing for traveling nurses and specialists against larger hospitals to backfill positions open from sick or quarantining staffers has been challenging. When the hospital has been faced with increasing numbers of covid patients seeking emergency care, handling "normal" emergencies like Connolly's has been much more difficult, Welch said.
While staffers work to transfer patients as close to home as possible, with so many hospitals in Kansas beyond capacity, it has become more common than before to transfer as far away as Colorado and Nebraska. Such transfers require medical flights, which are typically not covered by insurance and can cost patients upward of $50,000, Welch said.
"It is collateral damage," he said. "It is something that has sort of been lost out of the narrative of these folks where everybody is relieved when we find them a bed. Everybody forgets about the downstream impact of the cost of those transports."
Connolly recovered after three days in the Salina hospital. But the question still looms about the costs for her emergency care. Connolly had left her job as a corrections officer at the prison in September because coronavirus cases began to spike inside. Without her employer-sponsored health insurance, Connolly now relies on Medicaid and Medicare Part A, which means she is responsible for more out-of-pocket costs for things like pharmaceuticals and ambulance services.
Connolly worries so much about her finances that she's been too scared to look at her recent ambulance bills. Being a single parent, living with kidney failure and undergoing dialysis during a pandemic are her primary concerns.
As with many underlying conditions, covid-19 appears to pose an extra risk for people with kidney failure and patients undergoing dialysis, said Dr. Alan Kliger, a nephrologist at Yale University and co-chair of the American Society of Nephrology's COVID-19 Response Team.
Data from New York and Europe early in the pandemic showed that about 1 in 5 dialysis patients who acquired covid died, he said. However, the complication and mortality rates have fallen in recent months, according to unpublished survey data from members of the nephrology society, Kliger said.
"It's still a high risk," he said.
For Connolly, the pandemic has also complicated her three-times-a-week 3½-hour dialysis schedule. For example, when her daughter's kindergarten class was told to quarantine for 14 days after an in-class exposure to the virus, she had to scramble to find babysitters so she could attend dialysis.
"I don't want too many people to watch her because of covid," Connolly said of her daughter, adding that she is lucky the girl's father is supportive. But he can't always step in, which means if Connolly can't find a sitter, she may have to skip or reschedule dialysis.
Connolly wants to get another job. But living in a county where so many refuse to wear masks and some elected leaders accuse the health department of providing false information about covid testing rates and statistics makes her afraid to be in public more than necessary.
"I want to work," she said. "I had a good job. I served my community. The reality of knowing how bad it is at the hospital — I have seen it firsthand. And now I am out and seeing people without masks and I am thinking, 'If I get this and I have to go back, I may not leave the hospital next time.'"
The reality, said Kliger, Welch and others, is that while the virus runs rampant, hospitals will struggle to keep up, which potentially endangers medical staffers and anyone needing hospital care — and the virus will continue to spread as long as people refuse to wear masks and disregard scientifically sound guidelines.
Connolly said she would love to see more empathy for people who have underlying health concerns like her from those resisting safety measures such as masks.
"Even if they think that it doesn't work, what if it does? What if it could? I don't really understand how wearing a mask is going to take so much out of your day, compared to someone who is immunocompromised and gets sick," said Connolly. "Or you lose your grandma, or your parent. That's going to affect your life a lot longer than wearing a mask for a little while."
The Democratic majority in the Senate is too small to eliminate the filibuster, meaning Democrats will not have enough votes to pass many of their plans without Republicans.
This article was published on Monday, January 11, 2021 in Kaiser Health News
Democrats have argued for more generous pandemic relief, more pressure on drugmakers to lower prices and more attention to systemic racism in healthcare. On Jan. 20, with control of the Senate and the House of Representatives, they'll have the power to choose which healthcare proposals get a vote in Congress.
The victories of the Rev. Raphael Warnock and Jon Ossoff in Georgia last week gave Democrats two more Senate seats and the upper hand in the Senate's now 50-50 split. After Vice President-elect Kamala Harris takes the oath of office, she will serve as the tiebreaker as needed — in effect, Democrats' 51st vote.
But that vote count is too small to eliminate the filibuster, meaning Democrats will not have enough votes to pass many of their plans without Republicans. That will likely doom many Democratic healthcare proposals, like offering Americans a government-sponsored public insurance option, and complicate efforts to pass further pandemic relief.
It remains to be seen how willing lawmakers are to compromise with one another in the aftermath of a pro-Trump mob's breach of the Capitol on Wednesday. Thursday, Democrats demanded the president's removal for inciting rioters who disrupted the certification of President-elect Joe Biden's victory, assaulted Capitol Police officers and damaged federal property. One demonstrator and a police officer were killed, and three demonstrators died of medical emergencies.
Democrats' slim margins in the Senate and the House — where they can afford to lose only four votes and still pass legislation — will also give individual lawmakers more leverage, handing those who disagree with party leaders an incentive to push their own priorities in exchange for their votes. There will be little room for intraparty disagreements, and Democrats made it clear during the presidential primaries that they disagree about how to achieve their healthcare goals.
In less than two weeks, Democrats will lead the committees charged with marking up healthcare legislation and vetting Biden's health nominees.
The change will hand control of the Senate Health, Education, Labor and Pensions Committee to Sen. Patty Murray (D-Wash.), who brokered the 2013 agreement with then-House Speaker Paul Ryan that ended a long government shutdown, among other bipartisan deals.
In 2019, Murray and the committee's Republican chairman, Sen. Lamar Alexander of Tennessee, introduced a wide-ranging package to lower health costs for consumers. Among its proposals was an initiative to lower prescription drug prices by eliminating loopholes that allow brand-name drugmakers to block competition.
In an interview before Democrats secured the Senate, Murray said her committee work will be focused on the problems that prevent all Americans from receiving equitable, affordable treatment in healthcare. Racial disparities, evidenced by disproportionate mortality rates among Black mothers and among communities of color suffering the worst impacts of the pandemic, will be a priority, she said.
"Not everybody goes into the doctor and gets the same advice, feels the same comfort level and is believed," Murray said.
Murray said she will press for senators to consider how any piece of legislation will affect communities of color. "It will be the question I ask about every step we take," she said.
On Wednesday, she called out Republicans for standing in the way of fighting the pandemic "with policies that would directly help those struggling the most and would help us build back from this crisis stronger and fairer."
"With a Biden-Harris Administration and a Senate Democratic majority, the challenges we face won't get any less tough — but we've finally got the opportunity to face them head on and start taking action," Murray said in a statement. "I can't wait to start getting things done."
The Senate Finance Committee, which oversees Medicare, Medicaid and health-related tax policies, will be run by Sen. Ron Wyden (D-Ore.). While the HELP committee will also hold a confirmation hearing for Biden's nominee for secretary of the Department of Health and Human Services, Xavier Becerra, it is the Finance Committee that will vote to advance his confirmation.
Senate Republicans signaled they would delay considering Becerra's nomination before Biden officially announced his name last month. Calling him unqualified due to his lack of a healthcare background, they questioned his support for a single-payer healthcare system and opposed his efforts to preserve abortion rights. As California's attorney general, Becerra led efforts to fight lawsuits brought by Republican state officials against the Affordable Care Act.
But Democrats' slim edge in the Senate is expected to be enough to drown out Republicans' objections to the nomination. Last month, praising Becerra's commitment to responding to the pandemic, protecting healthcare coverage and addressing racial disparities, Wyden said he looked forward to Becerra's hearing "so he can get on the job and start helping people during this unprecedented crisis."
Also, after months of decrying the Trump administration's failures managing the pandemic, Democrats will control which relief bills get a vote.
Last month's package did not include their demands for more funding for state and local governments, and House Republicans blocked a Democratic effort to increase stimulus checks to $2,000, from $600.
Democrats have been united in their calls for more assistance, though they have disagreed at times about how to push for it.
In the fall, with the election approaching and no deal in sight, moderate Democrats in tough races pushed for House Speaker Nancy Pelosi to abandon negotiations for a $2.2 trillion relief package that Republicans called a nonstarter in favor of passing more modest but desperately needed relief.
"Every member of the leadership team, Democrats and Republicans, have messed up. Everyone is accountable," Rep. Max Rose (D-N.Y.) told Politico. "Get something done. Get something done!" He lost his bid for reelection.
More progressive voices like Rep. Alexandria Ocasio-Cortez (D-N.Y.) and Sen. Bernie Sanders (I-Vt.) have been a force for more generous aid, particularly larger stimulus checks.
Beyond the pandemic, top Democrats have mentioned drug pricing as another area ripe for action. But one of their most popular proposals, which would authorize the federal government to negotiate drug prices for those on Medicare, is unlikely to attract the Republican votes it would need. When House Democrats passed one such proposal in 2019, Senate Republicans vowed it would never pass.
Members of Democrats' more progressive wing, for their part, argued the proposal may not go far enough.
After years of Republican efforts to undermine the Affordable Care Act, though, it looks likely that efforts to stabilize the law could gain more traction under a Democratic-controlled Congress. The House passed legislation last summer aimed at increasing coverage and affordability, including by capping insurance costs at no more than 8.5% of income and expanding subsidies.
Lawmakers like Murray and Wyden have been quick to point out that the pandemic's devastating consequences — lost jobs and lost insurance coverage, to name just a couple — have only underscored the need to strengthen the healthcare system.
As the rollout of covid-19 vaccines picks up across the U.S., moving from hospital distribution to pharmacies, pop-up sites and drive-thru clinics, health experts say it's vital that these expanded venues be prepared to handle rare but potentially life-threatening allergic reactions.
"You want to be able to treat anaphylaxis," said Dr. Mitchell Grayson, an allergist-immunologist with Nationwide Children's Hospital in Columbus, Ohio. "I hope they're in a place where an ambulance can arrive within five to 10 minutes."
Of the more than 6 million people in the U.S. who have received shots of the two new covid vaccines, at least 29 have suffered anaphylaxis, a severe and dangerous reaction that can constrict airways and send the body into shock, according to the Centers for Disease Control and Prevention.
Such incidents have been rare — about 5.5 cases for every million doses of vaccine administered in the U.S. between mid-December and early January — and the patients recovered. For most people, the risk of getting the coronavirus is far higher than the risk of a vaccine reaction and is not a reason to avoid the shots, Grayson said.
Still, the rate of anaphylaxis so far is about five times higher for the covid vaccines than for flu shots, and some of those stricken had no history of allergic reactions. In this early phase of the vaccine rollout, all the patients were treated in hospitals and health centers that could offer immediate access to full-service emergency care.
As states look to scale up distribution, the shots will be administered by a varied assortment of professionals at venues including drugstores, dental offices and temporary sites attended by National Guard troops, among others. Health officials say every site involved in the wider community rollout must be able to recognize problems and have the training and equipment to respond swiftly if something goes wrong.
"We are really pushing to make sure that anybody administering vaccines needs not just to have the EpiPen available but, frankly, to know how to use it," said Dr. Nancy Messonnier, director of the CDC's National Center for Immunization and Respiratory Diseases, in a call with reporters. She was referring to a common epinephrine injector that many people with severe allergies carry with them. Those healthcare workers must also know the warning signs of the need for advanced care, she added.
Anaphylaxis typically occurs within minutes and can cause hives, nausea, vomiting, dizziness or fainting, and life-threatening problems such as low blood pressure and constricted airways. Initial treatment is an injection of epinephrine, or adrenalin, to reduce the body's allergic response. However, severely affected patients can require intensive treatments including oxygen, IV antihistamines and steroids such as cortisone to save their lives. Community sites are unlikely to have these treatments on hand and would need quick access to emergency responders.
Scientists are still investigating what's triggering the severe reactions to the Pfizer-BioNTech and Moderna mRNA vaccines. They suspect the culprit may be polyethylene glycol, or PEG, a component present in both vaccines that has been associated with allergic reactions.
Even as they call for education and support for providers, experts are urging the more than 50 million Americans with allergies — whether to foods, insect venom, medications or other vaccines — to be proactive about finding a venue that's properly prepared. Before scheduling a vaccine, contact the site and ask pointed questions about its emergency precautions, said Dr. Kimberly Blumenthal, quality and safety officer for allergy at Massachusetts General Hospital.
"Ask the question: Do they have an anaphylaxis kit? Can they take vital signs?" she said. People who routinely carry EpiPens should remember to bring them when they are vaccinated, she added.
A CDC website details a list of equipment and medications that sites should have on hand and urges that all patients be observed for 15 minutes after vaccination or 30 minutes if they're at higher risk for reactions. The list recommends — but does not require — that sites stock the more intensive treatments, such as IV fluids. People who experience severe reactions shouldn't get the recommended second dose of the vaccine, the agency said.
"Appropriate medical treatment for severe allergic reactions must be immediately available in the event that an acute anaphylactic reaction occurs following administration of an mRNA COVID-19 vaccine," the site says.
Still, that's a tall order, given the scope of the vaccination effort. The federal government is sending vaccines to more than 40,000 pharmacy locations involving 19 chains, including CVS, Walgreens, Costco and Rite Aid. At the same time, dozens of pop-up inoculation sites are ramping up in New York City, and drive-thru clinics have been set up in Ohio, Florida and other states.
Drive-thru sites, in particular, worry allergists like Blumenthal, who said it's crucial to recognize symptoms of anaphylaxis quickly. "If you're in a car, are you going to have your windows open? Where are the medicines? Are you in a parking lot?" she said. "It just sounds logistically more challenging."
In Columbus, more than 2,400 people had been vaccinated by Jan. 6 at a drive-thru clinic set up at the Ohio Expo Center. No allergic reactions have been reported, according to Kelli Newman, a spokesperson for Columbus Public Health. But if they occur, she said, health officials are prepared.
"We have a partnership with our EMS and they are observing those being vaccinated for 15 minutes to make sure there are no adverse reactions," Newman said in an email. "They have two EMS trucks available with emergency equipment and epinephrine, if needed."
Similarly, representatives for CVS Health and Walgreens said they have the staff and supplies to handle "rare but severe" reactions.
"We have emergency management protocols in place that are required for all vaccine providers, which, following a clinical assessment, may include administering epinephrine, calling 911 and administering CPR, if needed," Rebekah Pajak, a spokesperson for Walgreens, said in an email.
If the vaccine sites have appropriately trained staffers, plus adequate supplies and equipment, the vast majority of people should opt for the shot, especially as the pandemic continues to surge, said Dr. David Lang, immediate past president of the American Academy of Allergy, Asthma & Immunology and chairman of the department of immunology at the Cleveland Clinic.
"The overwhelming likelihood is that you won't have anaphylaxis and the overwhelming benefit far exceeds the risk for harm," Lang said.
With supplies of covid-19 vaccines scarce, a federal advisory panel recommends first putting shots into the arms of health care workers, who keep the nation’s medical system running, and long-term care residents most likely to die from the coronavirus.
Nowhere on the list of prioritized recipients are public officials’ spouses.
Yet the first ladies of Kentucky and West Virginia; Republican Vice President Mike Pence’s wife, Karen Pence; Democratic President-elect Joe Biden’s wife, Jill Biden; and Vice President-elect Kamala Harris’ husband, Doug Emhoff, were among the first Americans to get the potentially lifesaving shots.
Kentucky also vaccinated six former governors and four former first ladies, including current Democratic Gov. Andy Beshear’s parents.
The early vaccinations of political spouses spurred outrage on social media, with several Twitter users saying they should not be able to “jump the line” ahead of doctors, nurses and older people.
In most of the 29 states that responded to KHN inquiries of all 50 governors’ offices, top elected officials said they — and their spouses — will be vaccinated but have chosen to wait their turn behind more vulnerable constituents. Some Congress members from both parties said much the same when they refused early doses offered in the name of keeping the government running. Those weren’t offered to their spouses.
Governors who got the shots along with their spouses, and the vice president’s office, said they wanted to set an example for residents, build trust, bridge ideological divides and show that the vaccine is safe and effective.
But that’s a rationale some critics don’t buy.
“It looks more like cutting in line than it does securing trust. The politicians can get the hospitals to give it to them under this illusion of building trust. But it’s a façade,” said Arthur Caplan, a bioethics professor and founding head of the medical ethics division at New York University Grossman School of Medicine. “People might say: ‘Yup, typical rich people. They can’t be trusted.’ This undermines what they set out to do.”
Besides, Caplan said, the public doesn’t trust politicians all that much anyway, so inoculating celebrities, religious leaders or sports figures would likely do more to boost confidence in the vaccine. Rock ’n’ roll king Elvis Presley famously got the polio vaccine in 1956 to help win over those who were skeptical; the actions of governors’ wives from that period are less remembered.
Dr. José Romero, chairperson of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, said in an email to KHN that while his group provides an outline for distributing limited vaccine doses, “jurisdictions have the flexibility to do what’s appropriate for their population.” Kentucky and Texas officials pointed out that CDC Director Dr. Robert Redfield encouraged governors to publicly get the vaccine.
No one mentioned medical reasons for their spouses to get vaccines; hospitals are generally not vaccinating the spouses of medical professionals who have gotten the shot. (It’s unclear whether vaccinated people can still spread the virus, so it’s possible that a vaccinated person could pass the virus to their spouse or have to quarantine if an unvaccinated spouse were to get covid.)
The office of West Virginia’s governor, Republican Jim Justice, released pictures of him, his wife, Cathy Justice, and other officials receiving shots. He also showed his own vaccination on YouTube.
Beshear’s office in Kentucky also released photos of him getting the vaccine in December on the same day as his wife, Britainy Beshear, and other state officials.
“There is no question that there is vaccine hesitancy out there,” Beshear said at a coronavirus briefing on Monday, the day former Kentucky governors and their spouses were vaccinated. He alluded to a future program involving faith leaders and others. “Validators are incredibly important to building that confidence.”
His father, Democratic former Gov. Steve Beshear, posted photos of his vaccination on his Facebook page, saying that he and his wife, Jane Beshear, along with other former Kentucky governors of both parties and their spouses, stepped up partly to show residents the vaccine is safe and encourage them to get it when it’s available to them.
Kentucky is currently in the first stage of vaccine distribution, which targets health care workers and residents of long-term care and assisted living facilities. Fewer than 15,000 of the 58,500 doses received for long-term care had been given out when the former governors and their spouses were vaccinated.
Tres Watson, a former communications director for the Republican Party of Kentucky who founded a political consulting firm, was skeptical about the intentions behind the event. He said it seemed to be a public relations effort created so the governor could vaccinate his parents.
“I understand the continuity of government, but first ladies have no part in the continuity of government,” he said. “You need to stick with the priorities. Once you start making exceptions, that’s when you run into problems.”
Officials representing the Biden-Harris transition team and three other states where governors got vaccinated — Republican-led West Virginia and Texas, and Democratic-led Kansas — either didn’t respond to KHN or didn’t answer questions about spouses. Alabama’s Republican governor, Kay Ivey, got the vaccine and is divorced.
Politicians in other states have taken the opposite tack.
In Arkansas, Republican Gov. Asa Hutchinson is focused on ensuring high-priority groups such as health care workers, long-term care staffers and residents are vaccinated, said spokesperson LaConda Watson. “He and his wife will receive the vaccination when it’s their turn,” she said.
In Missouri, Kelli Jones, communications director for Republican Gov. Mike Parson, said in an email that he and the first lady fully intend to get the vaccine. Like governors from Colorado, Nevada and elsewhere, they’ve both recovered from covid-19, Jones said, and will “wait until their age group is eligible” under the state plan. Doctors recommend vaccinations even for people who have already had covid.
Cissy Sanders, 52, an events manager who lives in Austin, Texas, said she understands why lawmakers would need to get the vaccine. Her own governor, Republican Greg Abbott, received it on live television to instill confidence, said his press secretary, Renae Eze, who wouldn’t address whether Abbott’s wife was vaccinated.
But Sanders said politicians’ spouses should not be vaccinated before nursing home residents like her 71-year-old mom. Sanders’ mother received the vaccine in late December — after some public officials’ spouses — but she said far too many nursing home residents across America are still waiting.
“Why is a non-high-risk group — i.e., these spouses — going before the most high-risk group? Who makes these decisions? Who thinks this is a good, responsible, safe decision to make?” she said. “Political spouses have not been at ground zero for the virus. Nursing home residents have been.”
KHN Montana correspondent Katheryn Houghton, California Healthline correspondent Angela Hart and KHN senior correspondents Markian Hawryluk and JoNel Aleccia contributed to this report.
The approval is a 10-year "experiment." Instead of the open-ended federal funding that rises with higher enrollment and health costs, Tennessee will instead get an annual block grant.
This article was published on Friday, January 8, 2021 in Kaiser Health News.
With just a dozen days left in power, the Trump administration on Friday approved a radically different Medicaid financing system in Tennessee that for the first time would give the state broad authority in running the health insurance program for the poor in exchange for capping its annual federal funding.
The approval is a 10-year “experiment.” Instead of the open-ended federal funding that rises with higher enrollment and health costs, Tennessee will instead get an annual block grant. The approach has been pushed for decades by conservatives who say states too often chafe under strict federal guidelines about enrollment and coverage and can find ways to provide care more efficiently.
The approval, however, faces an uncertain future because the incoming Biden administration is likely to oppose such a move. But to unravel it, officials would need to set up a review that includes a public hearing.
Meanwhile, the changes in Tennessee will take months to implement because they need final legislative approval, and state officials must negotiate quality of care targets with the administration.
TennCare, the state’s Medicaid program, said the block grant system would give it unprecedented flexibility to decide who is covered and what services it will pay for.
It said the new arrangement would allow the state to keep part of the money it saves from operating the program more efficiently. Trump administration officials said the approach adds incentive for the state to save money, unlike the current system, in which increased state spending is matched with more federal dollars. If Medicaid enrollment grows, the state can secure additional federal funding. If enrollment drops, it will get less money.
“This groundbreaking waiver puts guardrails in place to ensure appropriate oversight and protections for beneficiaries, while also creating incentives for states to manage costs while holding them accountable for improving access, quality and health outcomes,” said Seema Verma, administrator of the Centers for Medicare & Medicaid Services. “It’s no exaggeration to say that this carefully crafted demonstration could be a national model moving forward.”
Opponents, including most advocates for low-income Americans, say the approach will threaten care for the 1.4 million people in TennCare, which includes children, pregnant women and the disabled. Federal funding covers two-thirds of the cost of the program.
Michele Johnson, executive director of the Tennessee Justice Center, said the block grant approval is a step backward for the state’s Medicaid program.
“No other state has sought a block grant, and for good reason. It gives state officials a blank check and creates financial incentives to cut health care to vulnerable families,” she said.
Democrats have fought back block grant Medicaid proposals since the Reagan administration and most recently in 2018 as part of Republicans’ failed effort to repeal and replace major parts of the Affordable Care Act. Even some key Republicans opposed the idea because it would cut billions in funding to states that would make it harder to help the poor.
Implementing block grants via an executive branch action rather than getting Congress to amend Medicaid law is also likely to be met with court challenges.
The block grant approval comes as Medicaid enrollment is at its highest ever level.
More than 76 million Americans are covered by the state-federal health program, a million more than when the Trump administration took charge in 2017. Enrollment has jumped by more than 5 million in the past year as the economy slumped with the pandemic.
Medicaid, part of President Lyndon B. Johnson’s “Great Society” initiative of the 1960s, is an entitlement program in which the government pays each state a certain percentage of the cost of care for anyone eligible for the health coverage. As a result, the more money states spend on Medicaid, the more they get from Washington.
Under the approved demonstration, CMS will work with Tennessee to set spending targets that will increase at a fixed amount each year.
The plan includes a “safety valve” to increase federal funding due to unexpected increases in enrollment.
“The safety valve will maintain Tennessee’s commitment to enroll all eligible Tennesseans with no reduction in today’s benefits for beneficiaries,” CMS said in a statement.
Tennessee has committed to maintaining coverage for eligible beneficiaries and existing services.
In exchange for taking on this financing approach, the state will receive a range of operating flexibilities from the federal government, as well as up to 55% of the savings generated on an annual basis when spending falls below the aggregate spending cap and the state meets certain quality targets, yet to be determined.
The state can spend that money on various health programs for residents, including areas that Medicaid funding typically doesn’t cover, such as improving transportation and education and employment.
The 10-year waiver is unusual, but the Trump administration has approved such long-term experiments in recent years to give states more flexibility.
Tennessee is one of 12 states that have not approved expanding Medicaid under the Affordable Care Act that’s left tens of thousands of working adults without health insurance.
“The block grant is just another example of putting politics ahead of health care during this pandemic,” said Johnson of the Tennessee Justice Center. “Now is absolutely not the time to waste our energy and resources limiting who can access health care.”
State officials applauded the approval.
“It’s a legacy accomplishment,” said Tennessee Gov. Bill Lee, a Republican. “This new flexibility means we can work toward improving maternal health coverage and clearing the waiting list for developmentally disabled.”
“This means we will be able to make additional investments in TennCare without reduction in services and provider cuts.”
KHN chief Washington correspondent Julie Rovner contributed to this report.
In recent weeks, it’s not just the number of positive cases that has increased, overwhelming the capacity of case investigators — so has the number of contacts that each infected person has.
This article was published on Friday, January 8, 2021 in Kaiser Health News. This story also ran on NPR.
The contact tracers of Washtenaw County in Michigan have been deluged with work and, to cope, the overburdened health department has a new tactic: It is asking residents who test positive for covid-19 to do their own contact tracing.
Washtenaw is a county of nearly 350,000 residents who live in and around the city of Ann Arbor, about 45 minutes from Detroit. Until mid-October, a county team of 15 contact tracers was managing the workload. But by Thanksgiving, more than 1,000 residents were testing positive for the coronavirus every week, and the tracers could not keep pace.
In Washtenaw County, the process starts with people called case investigators, who receive lab reports of positive coronavirus tests. Their job is to call anyone who has tested positive, tell them they need to isolate and ask them for the names of people with whom they have had close contact. After creating a list of potentially exposed “contacts,” investigators pass it to a new team to start the actual contact tracing. As the number of positive cases builds, the number of calls tracers must make swells.
But in recent weeks, it’s not just the number of positive cases that has increased, overwhelming the capacity of case investigators — so has the number of contacts that each infected person has, said contact tracer Madeline Bacolor.
“There’s just so many more people that are gathering and that are exposed,” she said. “It used to be, we had a case, and maybe that person had seen two people, and now it’s a whole classroom full of day care students or a whole workplace.”
The work to keep people who have been exposed to the virus away from people who have not is crucial, said public health professor Angela Beck, because it breaks viral transmission chains and prevents the virus from spreading unchecked through a community.
Beck teaches at the University of Michigan and runs the campus program for tracing coronavirus exposures among students.
When you’re trying to contain an infectious disease, she said, running out of contact tracers is “not a situation that you want to be in.”
But it’s happening now in health departments in Michigan and around the U.S. where contact tracing workforces have grown, but not fast enough to keep pace with the pandemic’s spread.
As a result, health departments are asking some residents with covid to reach out to their contacts on their own.
Trying ‘a Compromised Strategy’
Once billed as one of the fundamental tools for stemming the spread of the virus, contact tracing has fallen apart in many regions of the country. It’s a systematic breakdown that Lawrence Gostin, a professor of global health law at Georgetown University, said hasn’t happened since the spread and stigma of HIV and AIDS in the 1980s and ’90s.
In Michigan’s rural Upper Peninsula, a public health district spanning five counties warned residents that its tracers were overwhelmed and that they might not receive a call at all, despite testing positive. Health workers would need to focus their efforts on residents 65 and older, teens and children attending school in person, and people living in group settings.
In Michigan’s southwestern corner, contact tracers in Van Buren and Cass counties can no longer keep up with their calls. It’s the same situation in Berrien County: “If you test positive, take action immediately by isolating and notifying close contacts,” the county health officer urged residents in a press release.
Health officials have taken similar actions in all regions of the country, including Oregon, North Dakota, Ohio and Virginia.
Within many health departments, the shortage of contact tracers has been exacerbated by the communications challenge of relaying a recent change in quarantine guidance from the Centers for Disease Control and Prevention — it reduced the quarantine period from 14 days to 10 for some individuals exposed to the virus.
The idea behind the change was that the risk of transmission after 10 days of quarantine was low, and shorter quarantine periods might increase people’s willingness to comply with the orders. But the shift also meant that contact tracers had to spend time learning and explaining the new procedures just when caseloads were exploding.
“It makes things more confusing,” said Bacolor, the contact tracer in Washtenaw County. “People might be hearing something different from their job or school than they are from the health department.”
Asking infected people, some of whom might be sick, to call their own friends and families — in effect, conduct their own contact-tracing operation — is far from ideal, public health experts said.
“It is a last-resort tool,” said Beck, the University of Michigan professor. “It is the best that we can do in the situation that we’re in, but it’s a compromised strategy.”
Contact tracing is more than just alerting people to a potential exposure so they can quarantine. Part of the process is to conduct carefully structured interviews with those exposed, to determine if they’ve developed symptoms of covid-19. If so, contacts of those people also need to be traced and told to quarantine, to prevent the virus from proliferating through successive chains of people in the community.
Trained contact tracers also often ask valuable questions to learn more about how the virus was transmitted from person to person so that local health officials can piece together an understanding about which settings and activities seem particularly likely to promote spread — in-person choir rehearsals and crowded bars, for example — and which are unlikely to generate outbreaks.
Contact tracing is a key part of a tried-and-true strategy known as “test, trace and isolate.” Public health professor Beck said the strategy has been used allovertheworld and it works — when there are enough people and enough time to do it properly.
And she said effective contact tracing can help mitigate the economic pain of a pandemic because it means that only people with known exposures to the virus must stay away from workplaces and school and refrain from other activities.
But success requires significant investment in public health infrastructure, something that Beck and other researchers said has been lacking for decades in the U.S.
Executive orders issued by the president can be summarily overturned by a new executive order. Agency "guidance" can similarly be written over, although the Trump administration has worked to make that more onerous.
This article was published on Friday, January 8, 2021 in Kaiser Health News.
The party split in Congress is so slim that, even with Democrats technically in the majority, passing major healthcare legislation will be extremely difficult. So speculation about President-elect Joe Biden's health agenda has focused on the things he can accomplish using executive authority. Although there is a long list of things he could do, even longer is the list of things he is being urged to undo — actions taken by President Donald Trump.
While Trump was not able to make good on his highest-profile health-related promises from his 2016 campaign — including repealing the Affordable Care Act and broadly lowering prescription drug prices — his administration did make substantial changes to the nation's healthcare system using executive branch authority. And many of those changes are anathema to Democrats, particularly those aimed at hobbling the ACA.
For example, the Trump administration made it easier for those who buy their own insurance to purchase cheaper plans that don't cover all the ACA benefits and may not cover preexisting conditions. It also eliminated protections from discrimination in healthcare to people who are transgender.
Trump's use of tools like regulations, guidance and executive orders to modify health programs "was like an attack by a thousand paper cuts," said Maura Calsyn, managing director of health policy at the Center for American Progress, a Democratic think tank. Approaching the November election, she said, "the administration was in the process of doing irreparable harm to the nation's healthcare system."
Reversing many of those changes will be a big part of Biden's health agenda, in many cases coming even before trying to act on his own campaign pledges, such as creating a government-sponsored health plan for the ACA.
Chris Jennings, a health adviser to Presidents Barack Obama and Bill Clinton, said he refers to those Trump health policies as "bird droppings. As in you have to clean up the bird droppings before you have a clean slate."
Republicans, when they take over from a Democratic administration, think of their predecessor's policies the same way.
Though changing policies made by the executive branch seems easy, that's not always the case.
"These are issue-by-issue determinations that must be made, and they require process evaluation, legal evaluation, resource consideration and timeliness," said Jennings. In other words, some policies will take more time and personnel resources than others. And health policies will have to compete for White House attention with policies the new administration will want to change on anything from the environment to immigration to education.
Even within healthcare, issues as diverse as the operations of the ACA marketplaces, women's reproductive health and stem cell research will vie to be high on the list.
A Guide to Executive Actions
Some types of actions are easier to reverse than others.
Executive orders issued by the president, for example, can be summarily overturned by a new executive order. Agency "guidance" can similarly be written over, although the Trump administration has worked to make that more onerous.
Since the 1980s, for example, every time the presidency has changed parties, one of the incoming president's first actions has been to issue an executive order to either reimpose or eliminate the "Mexico City Policy" that governs funding for international family planning organizations that "perform or promote" abortion. Why do new administrations address abortion so quickly? Because the anniversary of the landmark Supreme Court abortion decision Roe v. Wade is two days after Inauguration Day, so the action is always politically timely.
Harder to change are formal regulations, such as one effectively banning Planned Parenthood from the federal family planning program, Title X. They are governed by a law, the Administrative Procedure Act, that lays out a very specific — and often time-consuming — process. "You have to cross your t's and dot your legal i's," said Nicholas Bagley, who teaches administrative law at the University of Michigan Law School.
And if you don't? Then regulations can be challenged in court — as those of the Trump administration were dozens of times. That's something Biden officials will take pains to avoid, said Calsyn. "I would expect to see very deliberate notice and comment rule-making, considering the reshaped judiciary" with so many Trump-appointed judges, she said.
What Comes First?
Undoing a previous administration's actions is an exercise in trying to push many things through a very narrow tube in a short time. Department regulations have to go not just through the leadership in each department, but also through the Office of Management and Budget "for a technical review, cost-benefit analysis and legal authority," said Bagley. "That can take time."
Complicating matters, many health regulations emanate not just from the Department of Health and Human Services, but jointly from HHS and other departments, including Labor and Treasury, which likely means more time to negotiate decisions among multiple departments.
Finally, said Bagley, "for really high-profile things, you've got to get the president's attention, and he's got limited time, too." Anything pandemic-related is likely to come first, he said.
Some items get pushed to the front of the line because of calendar considerations, as with the abortion executive orders. Others need more immediate attention because they are part of active court cases.
"You have all these court schedules and briefing schedules that will dictate the timeline where they make all these decisions," said Katie Keith, a health policy researcher and law professor at Georgetown University.
The Trump administration's efforts to allow states to set work requirements for many low-income adults who gained Medicaid coverage under the Affordable Care Act's expansion of the program is the highest-profile Trump action that falls into that latter category. The Supreme Court has agreed to hear a case challenging HHS approval of work requirements for Arkansas and New Hampshire in the next few months. Some Democrats are concerned about how the high court, with its new conservative majority, might rule, and the Biden administration will have to move fast if officials decide they want to head off that case.
But court actions also might help the Biden administration short-circuit the onerous regulatory process. If a regulation the new administration wants to rewrite or repeal has already been blocked by a court, Biden officials can simply choose not to appeal that ruling. That's what Trump did in ending insurance company subsidies for enrollees with low incomes in 2017.
Allowing a lower-court ruling to stand, however, is not a foolproof strategy. "That raises the possibility of having someone [else] intervene," said Keith. For example, Democratic attorneys general stepped in to defend the ACA in a case now pending at the Supreme Court when the Trump administration chose not to. "So, you have to be pretty strategic about not appealing," she said.
Adding On?
One other big decision for the incoming administration is whether it wants to use the opportunity to tweak or add to Trump policies rather than eliminate them. "Is it undoing and full stop?" asked Keith. "Or undoing and adding on?"
She said there is "a full slate of ideologically neutral" policies Trump put out, including ones on price transparency and prescription drugs. If Biden officials don't want to keep those as they are, they can rewrite them and advance other policies at the same time, saving a round of regulatory effort.
But none of it is easy — or fast.
One big problem is just having enough bodies available to do the work. "There was so much that undermined and hollowed out the federal workforce; there's a lot of rebuilding that needs to done," said Calsyn of the Center for American Progress. And Trump officials ran so roughshod over the regulatory process in many cases, she said, "even putting those processes back in place is going to be hard."
Incoming officials will also have other time-sensitive work to do. Writing regulations for the newly passed ban on "surprise" medical bills will almost certainly be a giant political fight between insurers and healthcare providers, who will try to re-litigate the legislation as it is implemented. Rules for insurers who sell policies under the ACA will need to be written almost immediately after Biden takes office.
Anyone waiting for a particular Trump policy to be wiped from the books will likely have to pack their patience. But law professor Bagley said he's optimistic it will all get done.
"One of the things we've grown unaccustomed to is a competent administration," he said. "When people are competent, they can do a lot of things pretty quickly."