The northern Rocky Mountains, Great Plains and Upper Midwest are seeing the highest surge of COVID-19 cases in the nation, as some residents have ignored recommendations for curtailing the virus.
This article was published on Monday, October 26, 2020 in Kaiser Health News.
COVID-19 cases are surging in rural places across the Mountain States and Midwest, and when it hits healthcare workers, ready reinforcements aren't easy to find.
In Montana, pandemic-induced staffing shortages have shuttered a clinic in the state's capital, led a northwestern regional hospital to ask employees exposed to COVID-19 to continue to work and emptied a health department 400 miles to the east.
"Just one more person out and we wouldn't be able to keep the surgeries going," said Dr. Shelly Harkins, chief medical officer of St. Peter's Health in Helena, a city of roughly 32,000 where cases continue to spread. "When the virus is just all around you, it's almost impossible to not be deemed a contact at some point. One case can take out a whole team of people in a blink of an eye."
In North Dakota, where cases per resident aregrowing faster than any other state, hospitals may once again curtail elective surgeries and possibly seek government aid to hire more nurses if the situation gets worse, North Dakota Hospital Association President Tim Blasl said.
"How long can we run at this rate with the workforce that we have?" Blasl said. "You can have all the licensed beds you want, but if you don't have anybody to staff those beds, it doesn't do you any good."
The northern Rocky Mountains, Great Plains and Upper Midwest are seeing the highest surge of COVID-19 cases in the nation, as some residents have ignored recommendations for curtailing the virus, such as wearing masks and avoiding large gatherings. Montana, Idaho, Utah, Wyoming, North Dakota, South Dakota, Nebraska, Iowa and Wisconsin have recently ranked among the top 10 U.S. states in confirmed cases per 100,000 residents over a seven-day period, according to an analysis by The New York Times.
Such coronavirus infections — and the quarantines that occur because of them — are exacerbating the healthcare worker shortage that existed in these states well before the pandemic. Unlike in the nation's metropolitan hubs, these outbreaks are scattered across hundreds of miles. And even in these states' biggest cities, the ranks of medical professionals are in short supply. Specialists and registered nurses are sometimes harder to track down than ventilators, N95 masks or hospital beds. Without enough care providers, patients may not be able to get the medical attention they need.
Hospitals have asked staffers to cover extra shifts and learn new skills. They have brought in temporary workers from other parts of the country and transferred some patients to less-crowded hospitals. But, at St. Peter's Health, if the hospital's one kidney doctor gets sick or is told to quarantine, Harkins doesn't expect to find a backup.
"We make a point to not have excessive staff because we have an obligation to keep the cost of healthcare down for a community — we just don't have a lot of slack in our rope," Harkins said. "What we don't account for is a mass exodus of staff for 14 days."
Some hospitals are already at patient capacity or are nearly there. That's not just because of the growing number of COVID-19 patients. Elective surgeries have resumed, and medical emergencies don't pause for a pandemic.
Some Montana hospitals formed agreements with local affiliates early in the pandemic to share staff if one came up short. But now that the disease is spreading fast — and widely — the hope is that their needs don't peak all at once.
Montana state officials keep a list of primarily in-state volunteer workers ready to travel to towns with shortages of contact tracers, nurses and more. But during a press conference on Oct. 15, Democratic Gov. Steve Bullock said the state had exhausted that database, and its nationwide request for National Guard medical staffing hadn't brought in new workers.
"If you are a registered nurse, licensed practical nurse, paramedic, EMT, CNA or contact tracer, and are able to join our workforce, please do consider joining our team," Bullock said.
This month, Kalispell Regional Medical Center in northwestern Montana even stopped quarantining COVID-exposed staff who remain asymptomatic, a change allowed by Centers for Disease Control and Prevention guidelinesfor health facilities facing staffing shortages.
"That's very telling for what staffing is going through right now," said Andrea Lueck, a registered nurse at the center. "We're so tight that employees are called off of quarantine."
Financial pressure early in the pandemic led the hospital to furlough staff, but it had to bring most of them back to work because it needs those bodies more than ever. The regional hub is based in Flathead County, which has recorded the state's second-highest number of active COVID-19 cases.
Mellody Sharpton, a hospital spokesperson, said hospital workers who are exposed to someone infected with the virus are tested within three to five days and monitored for symptoms. The hospital is also pulling in new workers, with 25 traveling health professionals on hand and another 25 temporary ones on the way.
But Sharpton said the best way to conserve the hospital's workforce is to stop the disease surge in the community.
Earlier in the pandemic, Central Montana Medical Center in Lewistown, a town of fewer than 6,000, experienced an exodus of part-time workers or those close to retirement who decided their jobs weren't worth the risk. The facility recently secured two traveling workers, but both backed out because they couldn't find housing. And, so far, roughly 40 of the hospital's 322 employees have missed work for reasons connected to COVID-19.
"We're at a critical staffing shortage and have been since the beginning of COVID," said Joanie Slaybaugh, Central Montana Medical Center's director of human resources. "We're small enough, everybody feels an obligation to protect themselves and to protect each other. But it doesn't take much to take out our staff."
Roosevelt County, where roughly 11,000 live on the northeastern edge of Montana, had one of the nation's highest rates of new cases as of Oct. 15. But by the end of the month, the county health department will lose half of its registered nurses as one person is about to retire and another was hired through a grant that's ending. That leaves only one registered nurse aside from its director, Patty Presser. The health department already had to close earlier during the pandemic because of COVID exposure and not enough staffers to cover the gap. Now, if Presser can't find nurse replacements in time, she hopes volunteers will step in, though she added they typically stay for only a few weeks.
"I need someone to do immunizations for my community, and you don't become an immunization nurse in 14 days," Presser said. "We don't have the workforce here to deal with this virus, not even right now, and then I'm going to have my best two people go."
Back in Helena, Harkins said St. Peter's Health had to close a specialty outpatient clinic that treats chronic diseases for two weeks at the end of September because the entire staff had to quarantine.
Now the hospital is considering having doctors take turns spending a week working from home, so that if another wave of quarantines hits in the hospital, at least one untainted person can be brought back to work. But that won't help for some specialties, like the hospital's sole kidney doctor.
Every time Harkins' phone rings, she said, she takes a breath and hopes it's not another case that will force a whole division to close.
"Because I think immediately of the hundreds of people that need that service and won't have it for 14 days," she said.
Mountain States editor Matt Volz contributed to this story.
Florida's plan to import cheaper prescription drugs from Canada — designed by Gov. Ron DeSantis and endorsed by President Donald Trump — has tasted its first bitter pill.
No private firms bid on Florida's $30 million contract to set up and operate a drug importation program. Bids were due at the end of September.
The setback is likely to delay by at least several months Florida's effort to become the first state to import drugs.
A spokesperson for the Florida Agency for Healthcare Administration said the state is exploring its options. "The agency remains confident it will find a qualified vendor soon," the spokesperson said. The state had planned to award a contract to a private vendor in December.
The disclosure of no bidders comes less than a month after the Trump administration cleared the way for states to apply for federal permission to set up an importation program — reversing nearly two decades of U.S. policy.
A 2003 law allows drug importation from Canada, but only if the head of the federal Department of Health and Human Services deems it safe and cost-effective. HHS Secretary Alex Azar made that declaration Sept. 24 and approved final rules for such initiatives.
Jane Horvath, a health consultant in College Park, Maryland, said potential bidders on the Florida contract were likely put off because the final federal rules were not set until late September. And private firms didn't want to bid on a contract that would have to change if the Florida rules conflicted with those from Washington, she said.
Several inconsistencies are apparent between the Florida plan and what is allowed under the HHS final rules, she said. For example, Florida aims to give bonus-scoring points to contractors that repackage and relabel drugs in Florida, which is not allowed under the federal rules.
Another problem is that the private contractor has to determine which prescription drugs will produce the most savings for Florida's Medicaid program, which is difficult since Medicaid rebates and other discount pricing are confidential.
"It could be that the $30 million contract is not enough either," Horvath said.
Drug prices are lower in Canada because the country limits how much drugmakers can charge for medicines. The United States lets drugmakers and their distributors dictate prices.
Trump, who made lowering prescription drug prices a key campaign issue in 2016, has promoted importation, especially in messages geared to seniors during his reelection bid.
Even with HHS backing, drug importation faces several challenges. Most notably, Canada has vowed to stop any effort that would exacerbate drug shortages there, which could make it challenging to identify a Canadian exporter. And the pharmaceutical industry opposes the program and is likely to sue to stop it.
Florida plans to set up an importation program to help lower drug prices for people covered by state programs such as Medicaid and the Corrections Department. The state has projected savings of up to $150 million a year.
The federal rules take effect Nov. 30, which is when states can formally apply to HHS to set up their program.
A chief architect of Florida's importation plan, Mary Mayhew, who was secretary of the Florida Agency for Healthcare Administration, resigned in September to become CEO of the Florida Hospital Association.
Mayhew refused to comment for this story.
Vermont, Colorado, Maine, New Hampshire and New Mexico are also devising programs to import drugs from Canada.
Colorado officials plan to seek out private contractors for that state's program in 2021, and they hope to get final federal approval by summer 2022, officials said during a recent call with stakeholder groups.
Colorado plans to allow consumers to get drugs from Canada at their U.S. pharmacy or through mail order. It estimates residents could save an average of 61% off the price of medicines in Colorado today.
It's unclear what impact the outcome of the presidential election will have on drug importation. Democratic nominee Joe Biden said he supports importing drugs from Canada. But, if elected, he is also likely to review many of the Trump administration's actions.
Dale Folwell has tried to persuade hospitals to accept lower payments, but he has struggled to discover the existing rates the plan pays each hospital.
This article was published on Monday, October 26, 2020 inKaiser Health News.
Cartel is a term frequently associated with illegal narcotics syndicates. In North Carolina, it has become the favored word of State Treasurer Dale Folwell to describe the state's hospital industry, the antagonist in his quest to lower healthcare prices for state employees.
The treasurer manages the state employees' health plan, which insures about 727,000 teachers, police officers, current and retired state workers and dependents. Folwell, a Republican, has tried to persuade hospitals to accept lower payments, but he has struggled to discover the existing rates the plan pays each hospital.
"These organizations' business model is secrecy," Folwell said, "from the billing all the way up to the way these hospitals' organizations receive their tax-exempt status."
Now, as Folwell, 62, seeks a second four-year term, the state's hospitals are coming after him.
The North Carolina Healthcare Association, the hospital trade group, has endorsed Folwell's Democratic challenger. It is a rare instance of a healthcare lobby seeking to topple an incumbent. Over 26 years, North Carolina's hospital association donated $2.1 million to sitting officeholders but bestowed just $29,700 to challengers, according to a tally from the National Institute on Money in Politics, a Montana-based nonprofit. All donations made this year will not be fully disclosed until after the election.
In many states, hospital associations are political powerhouses, with stables of lobbyists and the influence that comes with often being the largest employer in many legislative districts. In the previous election cycle of 2018, the hospital industry across the country donated $71 million to local and state candidates, political parties and ballot initiatives, according to the Money in Politics data. That amounted to a fifth of all spending by the healthcare industry and nearly three times that spent by pharmaceuticals and health products companies.
"The hospitals have very strong political clout in North Carolina, and increasingly so as they get bigger," said Aaron McKethan, a resident scholar at the Margolis Center for Health Policy at Duke University's Fuqua School of Business. "They are huge sources of employment. If anything, COVID has reinforced and strengthened them — the job of wagging your finger at hospitals over their prices has gotten harder."
Nationally, hospitals account for a third of healthcare spending. The prices hospitals charge private insurers including the state health plan are driving much of the increase in healthcare premiums. In North Carolina, hospital inpatient prices for private insurers rose by 10% from 2014 to 2018, according to the Healthcare Cost Institute.
Folwell's critics complain that, despite his verbal provocations about hospital power, his efforts to transform healthcare pricing have mostly fizzled. They also lament that he has made no effort to try to persuade the legislature to expand Medicaid, which would help shore up hospital finances.
"The treasurer has, for some reason, insisted on taking a 'my way or the highway' approach, rather than engage in honest conversations and negotiations," Cynthia Charles, the hospital association's spokesperson, said in an email. "As we have repeatedly said, we are willing to work together to redesign the plan in a manner to advance goals for cost reductions, price transparency and provider inclusion."
Folwell's Democratic challenger, Ronnie Chatterji, and the hospital industry insist a better way to bring health costs under control would be to tie payments to the quality of care, an approach Blue Cross and Blue Shield of North Carolina has begun experimenting with. With blunt cuts, "you're just going to put people's healthcare access in jeopardy," said Chatterji, an economist at the Fuqua School who served on former President Barack Obama's Council of Economic Advisers.
The bad blood between Folwell and North Carolina hospitals primarily traces back to 2018, when the treasurer told hospitals, doctors and other medical providers that to avoid having to ask the legislature for more money or raise employee contributions, he wanted to reduce by $300 million the amount the $3.3 billion health plan paid medical providers each year.
Folwell proposed to base prices on Medicare rates, an approach known as reference pricing. His plan offered to pay most hospitals 175% of what Medicare reimbursed them for inpatient services and 225% for outpatient services, on average. Rural hospitals, which tend to be in worse financial shape, would have received more, but their rates would also have been pegged to Medicare.
The plan would have amounted to a pay cut for most hospitals. A recent Rand Corp. study of hospital prices found that North Carolina hospitals in 2018 were paid on average 221% of Medicare rates for inpatient services and 334% of Medicare rates for outpatient services — well above what the treasurer was proposing.
The state's two big nonprofit systems, Atrium Health and Novant Health, earned substantially more, according to the Rand data. For example, Atrium Health Mercy hospital in Charlotte collected 423% of Medicare outpatient prices. Forsyth Medical Center in Winston-Salem, owned by Novant, collected 377% of what Medicare paid for outpatient services.
In its newsletter, the hospital association told its members that it tried to negotiate with the treasurer but that "Folwell has responded with disinterest and hostility towards these overtures and is instead engaging in a public campaign to malign hospitals."
The hospitals warned customers that if no agreement could be reached with the state plan, the hospitals would be classified as out-of-network providers and state employees would end up having to pay far more for their services.
Those arguments about financial penury obscured the fact that North Carolina's major hospital systems run huge surpluses in most years. Financial disclosure documents show that Atrium, which owns 36 hospitals in the state, ended 2019 with a$370 million surplus, a 6% margin. Novant, which owns 12 hospitals in North Carolina, that year earned $155 million, a 3% margin.
UNC Health, which amassed $271 million — a 6.4% margin — in its 2019 fiscal year, said in a statement that the treasurer's plan would have cost it $47 million in its 2020 fiscal year and "jeopardized the financial viability of some of our rural hospitals."
"We're overpaying for no reason but to build multimillion reserves for these hospital corporations," said Ardis Watkins, executive director of the State Employees Association of North Carolina.
Ultimately, the hospitals maintained a solid wall of opposition. Only three of North Carolina's 108 hospitals signed on to the treasurer's plan.
Duke's McKethan said it was "predictable" that the hospitals would refuse to give up the negotiating advantages they held. "On the diagnosis of the problem — we've got these opaque prices that vary — he's on solid ground," he said about Folwell. "But when a good idea runs into the disadvantageous structure of the healthcare market, it doesn't go anywhere."
Apart from hospitals, the treasurer had some success in persuading about 25,000 of the state's 60,000 doctors, therapists and other medical providers to accept the new payment system, which he named the Clear Pricing Project. Dr. Dale Owen, CEO of Tryon Medical Partners, a large independent physicians' group based in Charlotte, said his group's reimbursements will come out about the same under the plan.
"Quite honestly, even if it had been a tiny loss, no big deal because it was the right thing to do for everybody," said Owen, who formed his group with fellow physicians who seceded from Atrium. "What he's doing is, he's opening a sore and a problem that people have not been willing to deal with and pushed under the rug."
The Clear Pricing Project has yet to demonstrate the ability to save the state money. In fact, the effort may be costing the state more because many of the providers that signed on — such as primary care doctors and behavioral health specialists — are getting higher reimbursements than they had been while those that would have lost money, like hospitals, have stayed away.
Asked why he thought the hospitals would volunteer to forgo higher payments, Folwell said he had hoped they would realize that their long-term survival is endangered by the unsustainable increase in healthcare costs.
"I thought they would want to be partnering with a solution instead of the same old way," he said in an interview. "I don't think they accept the notion that they're going to be on the wrong side of history."
The hospital industry has been taking steps to try to make Folwell and his proposal history. During his attempt to get hospitals to agree to the pricing plan, the industry's allies in the legislature introduced a billthat would have blocked the state health plan from instituting any reference pricing plan through 2021. That effort ultimately died.
Folwell has continued to rankle the hospitals with his opposition to further concentration of hospital ownership. He has opposed the pending sale of a county-owned hospital based in Wilmington, which Novant is purchasing. That followed his 2018 attempt to challenge an ultimately unsuccessful merger of Atrium and UNC Health by requesting a $1 billion performance bond if the deal ultimately raised prices for the state health plan.
Last month, the hospital association gave Chatterji its endorsementwith a clear swipe at Folwell. The association's president, Steve Lawler, said in the statement that "it is apparent that Mr. Chatterji genuinely wants to collaborate."
It’s no surprise, then, that in an ad released this month, former Vice President Joe Biden’s campaign played the Medicare card.
“Donald Trump is lying about Medicare and Social Security,” an ominous, mature, male voice warns viewers in the ad. He goes on to say that “Trump’s pushing to slash Medicare benefits.”
Clearly, we’ve heard this dire message before — from candidates of both parties through the years.
We issued a skeptical rating of a claim that Trump promised to gut Social Security and Medicare if re-elected, noting that his deferral of payroll taxes did not mention Medicare at all. But Trump has not mentioned cuts to Medicare benefits on the trail, and he’s promised to make cuts to the program in the future. So what is Biden’s claim talking about?
As a rationale for the statement, a Biden campaign spokesperson pointed us to the Trump administration’s support of Republicans’ efforts in a court case, California v. Texas, which seeks to overturn the Affordable Care Act. But the ad does not include any reference or explanation of how the case would affect Medicare benefits.
The legal challenge, brought by a group of Republican attorneys general, is pegged to the 2017 tax bill, which zeroed out the tax that functioned as a penalty for not having health coverage — known as the individual mandate. Without this linchpin tax, the Republicans argue, the entire law should be struck down. They based that on the Supreme Court decision in 2012 that the law was constitutional because the penalty was a valid use of Congress’ ability to levy taxes.
In the current case, lower courts have found the law unconstitutional, and a group of Democratic attorneys general appealed to the Supreme Court.
Oral arguments are scheduled for Nov. 10. The Trump administration filed a brief in support of invalidating the entire law unconstitutional.
Though best known for its vast expansion of health coverage through marketplace plans and Medicaid, the ACA also included a range of consumer protections — such as the ban on discrimination against people with preexisting conditions — and an estimated 165 Medicare-related provisions.
The Biden spokesperson pointed to one, which ended Medicare’s so-called doughnut hole.
We asked experts for their take. Immediately, we found differences in opinion.
That’s a “perfectly fair claim,” said Nicholas Bagley, a professor at the University of Michigan Law School. Closing the doughnut hole matters to many people, he said.
Case Western Reserve University law professor Jonathan Adler took a different view. The argument that Medicare would be affected “is a very aggressive reading of the filing in this case,” he said, referring to the Trump administration’s brief in support of nullifying the ACA.
The next step seemed to be getting a better grasp of what’s at stake.
A Quick Review of the Doughnut Hole, Other Medicare Provisions
The Medicare doughnut hole refers to the gap in Part D prescription drug coverage that begins after a beneficiary spends a set amount — usually a few thousand dollars. Before the ACA, beneficiaries who reached that threshold were responsible for 100% of their medication costs until they spent enough for catastrophic coverage to kick in, which could be more than $1,000 in additional spending. Even with this coverage, beneficiaries were responsible for 5% of their drug expenditures. (If beneficiaries were responsible for 100% of costs today, people with high drug costs would obviously pay a lot more without the ACA provision.)
The ACA would have gradually ended that coverage gap. But, in 2018, Congress adopted changes to expedite the process. As of 2019, the doughnut hole was closed. Adler pointed to that congressional intervention as a step that could keep the doughnut hole closed if the ACA were overturned. Based on this legislative history, the argument could be made that closing the coverage gap was something Congress had an interest in apart from the ACA. Since the doughnut hole is officially closed, some analysts said this provision may not be vulnerable to the upcoming Supreme Court decision on the ACA.
“You can make a lot of claims,” said Gail Wilensky, a former head of the Centers for Medicare & Medicaid Services. “That one is really a stretch.”
Other ACA provisions tied to Medicare benefits seem more at risk, such as the one that mandated annual wellness visits and certain preventive services, such as mammograms, bone mass measurement for those with osteoporosis, and depression and diabetes screening, with no patient cost sharing.
“It’s not clear that the administration actively supports any change to the Medicare benefits with the case before SCOTUS,” said Tricia Neuman, KFF senior vice president and executive director of the KFF’s program on Medicare policy. “But if they didn’t explicitly seek to wall off certain provisions, it is at least conceivable — though maybe not likely — that Medicare benefits in the ACA could be collateral damage.” (KHN is an editorially independent program of KFF.)
According to an amicus brief filed by the AARP, the Center for Medicare Advocacy and Justice in Aging in 2016, an estimated 40.1 million Medicare beneficiaries received at least one preventive service and 10.3 million had an annual wellness visit with no copay or deductible.
Other experts pointed to a troubling implication for Medicare: the nullification of the ACA provisions related to costs and slowing the growth of the program’s spending. Those efforts had been credited with extending the solvency of the Health Insurance Trust Fund and slowing the growth in Medicare premiums.
It “would impair the financial fitness” of the trust fund, said Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities.
Trump “may not say it is his intent to slash Medicare benefits,” agreed David Lipschutz, associate director of the Center for Medicare Advocacy, but overturning the ACA entirely would “cause chaos writ large.” And, because of the program’s size, that chaos “would upend the financial markets and the entire health care system,” according to the brief filed by Medicare advocates.
What Comes Next Is Complicated
Enter the concept of severability. Many court watchers are quick to say the high court’s decision could go beyond upholding the entire law or declaring it unconstitutional. Instead, the justices could separate or sever parts of it not directly related to the zeroed-out tax penalty, the so-called individual mandate.
Of course, the Trump administration argued in its brief that the interwoven nature of the ACA’s provisions demanded that the entire law be invalidated.
“If you just go on that basis, they are not arguing for severability,” said Van de Water.
But others point out another layer that warrants consideration.
“Everyone who comments on this focuses on the administration’s argument for inseverability,” Adler said. But he said it was more complicated than that.
The Trump administration’s position is “simultaneously that the entire ACA should be invalidated” and also that relief should be provided only where injury to the plaintiffs is shown. (The administration defines the plaintiffs as the two individuals who signed on to the original challenge.)
Another view is that this point in the administration’s argument is not clear-cut, mostly because it gives no hint as to which programs or provisions would fit into the category of harming the plaintiffs.
Ultimately, the fate of the sweeping health law is in the hands of the Supreme Court.
“Legal analysts didn’t anticipate the case getting as far as it has,” said Lipschutz.
But “the White House threw its weight behind the lawsuit,” said Bagley, at the University of Michigan. “So, they own the consequences. Especially in the context of this presidential campaign.”
Our Ruling
An attack ad by the Biden campaign states that Trump is “pushing to slash Medicare benefits” and ties this charge to the administration’s position on the pending legal challenge to the ACA.
The Biden campaign pointed to an ACA provision that sought to close the Medicare doughnut hole to support this claim. It may not be the best example, though, because some experts suggest it may not be as vulnerable as other parts of the law.
Experts outlined a range of other Medicare provisions that either provided new benefits or shored up the program’s financial fitness. If the whole law were to be nullified, as the administration has advocated, these changes could also be erased — a step that would affect benefits and potentially cause premiums to rise.
Overall, the Biden ad seems plausible, even though the link between Trump’s position on the legal challenge and its impact on Medicare benefits is less straightforward than in similar claims we have checked regarding preexisting conditions.
During the final presidential debate, President Donald Trump claimed that 180 million people would lose their private health insurance to socialized medicine if the Democratic presidential nominee, former Vice President Joe Biden, is elected president.
“They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans,” said Trump.
Trump has repeated this claim throughout the week, and we thought the linkage of Biden’s proposed health care plan with socialism was something we needed to check out. Especially since Biden opposed “Medicare for All,” the proposal by Sen. Bernie Sanders (I-Vt.) that would have created a single-payer health system run completely by the federal government, and has long been attacked by Republicans as “socialist.”
The Trump campaign did not respond to our request asking where the evidence for this claim came from. Experts called it a distortion of Biden’s plan.
Where the Number Comes From
Experts agreed the number of people who have private health insurance either through an employer-sponsored plan or purchased on the Affordable Care Act’s health insurance marketplace is around 180 million people.
KFF, a nonpartisan health policy organization,estimated in 2018 that about 157 million Americans had health insurance through their employer, while almost 20 million had insurance they purchased for themselves. Together, that adds up to about 177 million with private health insurance. (KHN is an editorially independent program of KFF.)
What Does Biden Support?
Biden supports expanding the ACA through several measures, including a public option. Under his plan, this public option would be a health insurance plan run by the federal government that would be offered alongside other private health insurance plans on the insurance marketplace.
“The marketplace is made up of multiple insurers in areas,” said Linda Blumberg, a health policy fellow at the Urban Institute. “Sometimes there are five or more [plans]; sometimes there is only one. Biden is talking about adding a public option in the marketplace. You could pick between these private insurers or you could pick the public option.”
Getting rid of the so-called employer firewall is also part of Biden’s proposal.
This firewall was implemented during the rollout of the ACA. It was designed to maintain balance in the insurance risk pools by preventing too many healthy people who have work-based coverage from opting instead to move to a marketplace plan. And it all came down to who qualified for the subsidies that made these plans more affordable.
Currently, those who are offered a health insurance plan through their employer that meets certain minimum federal standards aren’t eligible to receive these subsidies, which come in the form of tax credits. But that leaves many low-income workers with health care plans that aren’t as affordable or comprehensive as marketplace plans.
Biden’s plan would eliminate that firewall, meaning anyone could choose to get health insurance either through their employer or through the marketplace. That’s where many Republicans argue that we could start to see leakage from private health insurance plans to the public option.
“The problem is healthy people leaving employer plans,” said Joseph Antos, a scholar in health care at the conservative-leaning American Enterprise Institute. That could mean the entire workplace plan’s premiums would go up. “You could easily imagine a plan where it spirals, the premiums go up, and then even more people start leaving the plans to go to the public option.”
Blumberg, though, said that because the marketplace would still include private health insurance plans alongside the public option, it doesn’t mean everyone who chooses to leave their employer plan would go straight to the public option.
She has done estimatesbased on a plan similar to the one Biden is proposing. She estimates that only about 10% to 12% of Americans would choose to leave their employer-sponsored plans, which translates to about 15 million to 18 million Americans.
Source List:
Email interview with Cynthia Cox, vice president and director for the Program on the ACA at KFF, Oct. 22, 2020
Email interview with Larry Levitt, executive vice president for health policy at KFF, Oct. 22, 2020
Email interview with Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University, Oct. 22, 2020
Phone interview with Joseph Antos, Wilson H. Taylor resident scholar in health care and retirement policy at the American Enterprise Institute, Oct. 22, 2020
Phone interview with Linda Blumberg, institute fellow in the Health Policy Center at the Urban Institute, Oct. 22, 2020
KFF also did an estimate and found that 12.3 million people with employer coverage could save money by buying on the exchange under the Biden plan.
But “it’s not clear all of those people would choose to leave their employer coverage, though, as there are other reasons besides costs that people might want to have job-based insurance,” Cynthia Cox, vice president and director of the program on the ACA at KFF, wrote in an email.
Either way, none of the estimates are anywhere close to the 180 million that Trump claimed.
Is This Type of Public Option Socialism?
Overall, experts said no, what Biden supports isn’t socialized medicine.
“Socialized medicine means that the government runs hospitals and employs doctors, and that is not part of Biden’s plan,” Larry Levitt, executive vice president for health policy at KFF, wrote in an email. “Under Biden’s plans, doctors and hospitals would remain in the private sector just like they are today.”
However, Antos said that, in his view, the definition of socialism can really vary when it comes to health care.
“I would argue in one sense, we would already have socialized medicine. We have massive federal subsidies for everybody, so in that sense, we’re already there,” said Antos. “But, if socialized medicine means the government is going to dictate how doctors practice or how health care is delivered, we are obviously not in that situation. I don’t think the Biden plan would lead you that way.”
And in the end, Antos said, invoking socialism is a scare tactic that politicians have been using for years.
“It’s just a political slur,” said Antos. “It’s meant to inflame the emotions of those who will vote for Trump and meant to annoy the people who will vote for Biden.”
Our Ruling
Trump said 180 million people would lose their private health insurance plans to socialized medicine under Biden.
While about 180 million people do have private health insurance, there is no evidence that all of them would lose their private plans if Biden were elected president.
Biden supports implementing a public option on the health insurance marketplace. It would exist alongside private health insurance plans, and Americans would have the option to buy either the private plan or the public plan. While estimates show that a number of Americans would likely leave their employer-sponsored coverage for the public plan, they would be doing that by choice and the estimates are nowhere near Trump’s 180 million figure.
Experts also agree that the public option is not socialized medicine, and it’s ridiculous to conflate Biden’s plan with Medicare for All.
When COVID-19 began making headlines in March, Charles Collins pulled out a protective face mask from the supply at the manufacturing company in Rockaway, New Jersey, where he was the shop foreman and put it on. The dozen or so other workers at the facility followed suit. There was no way to maintain a safe distance from one another on the shop floor, where they made safety mats for machines, and a few of the men had been out sick with flu-like symptoms. Better safe than sorry.
Management was not pleased. Collins got a text message from one of his supervisors saying masks were to be used to protect workers from wood chips, metal particles and other occupational safety hazards. "We don't provide or for that matter have enough masks to protect anybody from CORVID-19 [sic]!" If workers didn't stop using the masks for that purpose, the supervisor texted, "we'll have to store them away just like the candy!"
"I was shocked," said Collins, 38. "They weren't taking it seriously."
Shortly after that, Collins left for a planned vacation. When he returned a week later, the company told him to quarantine at home for two weeks because he'd been traveling.
But when the quarantine ended, Collins didn't want to go back to work. Co-workers, he said, told him that recommended safety measures such as wearing masks and maintaining social distancing hadn't been implemented. When he told human resources that he feared becoming infected and endangering his mother and his 8-year-old nephew who live with him, he said, he got an ultimatum: Return to work or resign.
Collins stayed home and says he was fired. He hired a lawyer and filed a complaint in the Superior Court of New Jersey under the state's whistleblower law, the Conscientious Employee Protection Act. The law prohibits employers from firing, demoting or otherwise retaliating against workers who refuse to take part in activities they believe are incompatible with public health and safety mandates.
As many employers, with the strong encouragement of the Trump administration, move to bring employees back, a growing number of workers are resisting what they feel are unsafe, unhealthy conditions. In recent months, a few states have passed laws specifically aimed at protecting workers who face COVID-related safety risks and retaliation for speaking up about them. Some states, like New Jersey, have whistleblower protection laws already. But advocates say stronger federal protections are needed.
The Occupational Safety and Health Administration, part of the U.S. Department of Labor, is responsible for enforcing 23 federal whistleblower statutes that protect workers from retaliation if they report workplace safety violations, among other problems.
But according to a new analysis, the agency isn't up to the task. The National Employment Law Project, a workers' advocacy and research group, found that of 1,744 COVID-related retaliation complaints filed with OSHA between April and mid-August, 20% were docketed for investigation and 2% were resolved. More than half were dismissed or closed without investigation.
"Even before COVID, workers had a really bad track record of getting any justice for their concerns if they were retaliated against," said Debbie Berkowitz, director of the worker health and safety program at the National Employment Law Project and a former senior OSHA official.
The numbers are growing. Whistleblower complaints filed with OSHA increased by 30% between February and May, to 4,101, according to an August report by the Department of Labor's Office of the Inspector General that criticized the agency's handling of the complaints.
Nearly 40% of the complaints — 1,618 — were related to COVID-19, the report found, filed primarily by workers who claimed they were punished for reporting workplace safety violations. Those could include, for example, not having appropriate personal protective equipment or sanitation materials, or a lack of social distancing on the job.
While complaints rose, the number of whistleblower investigators decreased from the previous year, according to the report. The average time it took to close an investigation at the end of March was roughly nine months.
Worker whistleblower protections under the Occupational Safety and Health law are "incredibly weak" compared with whistleblower statutes that protect employees who report other types of wrongdoing, Berkowitz said. If OSHA dismisses a complaint, workers have no right to appeal the decision, and once they file a complaint with OSHA they aren't permitted to take their case to court on their own, she said.
Consumer advocates would like to see those provisions changed.
"The Administration has remained committed to providing the Whistleblower Protection program with the resources it needs to fulfill its mission," a spokesperson for the Department of Labor wrote in an email to KHN. "In fiscal year 2020, OSHA asked for and received five new full-time employees and requested an additional ten in the President's budget for fiscal year 2021."
If workers don't pursue a whistleblower complaint through OSHA, they can file a state lawsuit claiming "wrongful discharge" or use a state's whistleblower law, as Collins did.
According to a COVID employment litigation tracker by Fisher Phillips, an employment law firm, since the beginning of the year 169 retaliation/whistleblower lawsuits have been filed across the country — the second-biggest category, behind suits related to remote work/leave, with 206 cases. An additional 27 lawsuits have been filed for wrongful discharge.
Juan Carlos Fernandez, the Morristown, New Jersey, attorney representing Charles Collins, said he's seen a significant uptick in inquiries from workers about safety concerns in recent months. Before the pandemic began, he typically received one or two such calls per month. Now, he gets three or four a day.
Many callers say they were terminated after they asked for protective equipment on the job, Fernandez said. Others had asked for time off to care for a family member or a child whose school had closed because of COVID-19 and then were told not to come back to work.
In addition to reporting safety violations, Collins' lawsuit claims, he was fired for asking to take time off. Under the federal Families First Coronavirus Response Act, employees are generally entitled to two weeks' paid leave if they're quarantined, and another two weeks' paid sick leave at two-thirds pay to care for a child whose school has closed, as well as expanded family and medical leave. Collins has cared for his nephew since his sister died two years ago in a car accident. His nephew's school closed in March because of COVID-19.
Collins said his employer, ASO Safety Solutions, paid him for only the first week of his company-ordered quarantine. Any additional time off would come out of his accrued sick and vacation time, he was told.
ASO Safety Solutions didn't respond to requests for comment, nor did the law firm representing the company.
In his response to the complaint submitted to the court, the lawyer representing the company denied that ASO had retaliated against Collins for whistleblowing, asserting he had resigned. The response, by John Olsen, with Ferdinand IP Law Group, also said that the provisions of the Families First Coronavirus Response Act do not apply to the company. The lawyers have exchanged requests for discovery, Fernandez said, which should be answered in the next several weeks.
A few states and cities have stepped in to help whistleblowers. Virginia was the first to put in place statewide workplace safety standards related to COVID-19, spurred by concerns from workers in poultry plants, said Rachel McFarland, a staff attorney at the Legal Aid Justice Center in Charlottesville. The standards include specific provisions protecting workers from retaliation for raising safety concerns or refusing to work in a location they believe is unsafe.
Colorado and the cities of Philadelphiaand Chicago likewise passed laws prohibiting employers from retaliating against workers who raise COVID-related safety concerns, refuse to work in unsafe conditions or take time off to minimize the transmission of the virus.
But these laws are the exceptions, said Brent Newell, a senior attorney at Public Justice in Oakland, California, who has represented the interests of workers in meatpacking plants. "Many states haven't done that and won't do that," he said. "For the federal government to put it on the states to protect workers is wholly and fundamentally inadequate."
Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.
This article was published on Thursday, October 22, 2020 in Kaiser Health News.
SACRAMENTO, Calif. — In an election year dominated by a chaotic presidential race and splashy statewide ballot initiative campaigns, Californians are being asked to weigh in on the value of stem cell research — again.
Proposition 14 would authorize the state to borrow $5.5 billion to keep financing the California Institute for Regenerative Medicine (CIRM), currently the second-largest funder of stem cell research in the world. Factoring in interest payments, the measure could cost the state roughly $7.8 billion over about 30 years, according to an estimate from the nonpartisan state Legislative Analyst’s Office.
In 2004, voters approved Proposition 71, a $3 billion bond, to be repaid with interest over 30 years. The measure got the state agency up and running and was designed to seed research.
During that first campaign, voters were told research funded by the measure could lead to cures for cancer, Alzheimer’s and other devastating diseases, and that the state could reap millions in royalties from new treatments.
Yet most of those ambitions remain unfulfilled.
“I think the initial promises were a little optimistic,” said Kevin McCormack, CIRM’s senior director of public communications, about how quickly research would yield cures. “You can’t rush this kind of work.”
So advocates are back after 16 years for more research money, and to increase the size of the state agency.
Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.
When the first bond measure was adopted in 2004, the George W. Bush administration refused to fund stem cell research at the national level because of opposition to the use of one kind of stem cell: human embryonic stem cells. They derive from fertilized eggs, which has made them controversial among politicians who oppose abortion.
Federal funding resumed in 2009, and thus far this year the National Institutes of Health has spent about $321 million on human embryonic stem cell research.
But advocates for Proposition 14 say the ability to do that research is still tenuous. In September, Republican lawmakers sent a letter to President Donald Trump urging him to cut off those funds once again.
The funding from California’s original bond measure was used to create the new state institute and fund grants to conduct research at California hospitals and universities for diseases such as blood cancer and kidney failure. The money has paid for 90 clinical trials.
A 2019 report from the University of Southern California concluded the center has contributed about $10.7 billion to the California economy, which includes hiring, construction and attracting more research dollars to the state. CIRM funds more than 56,500 jobs, more than half of which are considered high-paying.
Despite the campaign promises, just two treatments developed with some help from CIRM have been approved by the Food and Drug Administration in the past 13 years, one for leukemia and one for scarring of the bone marrow.
But it’s a bit of a stretch for the institute to take credit for these drugs, said Jeff Sheehy, a CIRM board member who does not support the new bond measure. He said the agency funded the researcher whose lab discovered and developed the drugs, but CIRM holds no rights to those drugs and doesn’t receive royalties from them.
The state has received about $518,000 in revenue from licensing other institute-funded discoveries, such as devices, McCormack said.
McCormack also pointed to some promising stem cell therapies still in clinical trials, such as a treatment that has cured 50 children of severe combined immunodeficiency, a genetic disorder often called “bubble baby” disease, and others that have led to “dramatic” improvements in paralysis and blindness, he said.
The campaigns for both bond measures may be giving people unrealistic expectations and false hope, said Marcy Darnovsky, executive director of the Center for Genetics and Society. “It undermines people’s trust in science,” Darnovsky said. “No one can promise cures, and nobody should.”
Robert Klein, a real estate developer who wrote both ballot measures, disagrees. He was inspired to invest in stem cell research after he lost his youngest son to Type 1 diabetes. He said some of CIRM’s breakthroughs are helping patients right now.
“What are you going to do if this doesn’t pass? Tell those people we’re sorry, but we’re not going to do this?” Klein said. “The thought of other children needlessly dying is unbearable.”
Sheehy, who has served on the agency’s board for 16 years, said he’s proud of the work the institute has done but believes it should be funded through the legislature, not by borrowing more money.
“The promise was that it would pay for itself and it hasn’t,” Sheehy said. “We can’t really afford it, and this is the worst way to pay for it.”
Even if CIRM isn’t turning a profit, some researchers and private companies are benefiting from the public money. Take the company Forty Seven Inc., named after a human protein and co-founded by Irving Weissman, director of Stanford University’s stem cell research program. The state stem cell agency awarded more than $15 million to Forty Seven, and $30 million to Weissman at Stanford for research.
That money fueled research that uncovered a promising treatment for several different cancers. Gilead Sciences, the pharmaceutical giant, bought Forty Seven in 2018 for $4.9 billion. Of that, $21.2 million went back to CIRM to pay back Forty Seven’s research grants, with interest.
“Gilead will make far more than that if it turns out to be lucrative,” said Ameet Sarpatwari, a professor of medicine at Harvard Medical School who studies drug development.
Because this kind of work is both expensive and risky, private companies are reluctant to pay for early research, when scientists have no idea if their work will yield results, let alone profits, Sarpatwari said. So the state pays for this work, and drug companies come in to finance later-stage research once a molecule looks promising — and ultimately reap the profits.
“We’re socializing the risk of drug development and privatizing the gains,” Sarpatwari said.
On paper, the institute has stricter pricing regulations than the NIH, which does not require that drugs developed with public money are accessible to the public. In California, companies have to submit plans for how uninsured patients will get medicine and are required to sell those medications to the state’s public health programs at a specified rate.
But in practice, the regulations have never really been tested.
Proposition 14 would add a new rule. It would take the money California makes from royalties and use it to help patients afford those treatments. It also benefits drug companies: Whatever revenue the state makes from these drugs will go back to the companies in the form of state-financed patient subsidies.
The measure also would establish a new working group (complete with 15 new, full-time staffers) that would help make clinical trials more affordable for patients by paying for lodging and transportation to the trials.
And it would increase the size of CIRM’s governing board from 29 to 35. This contradicts recommendations from the Institute of Medicine, which suggested shrinking the board to avoid conflicts of interest. Klein argues the extra board positions are necessary to represent different regions and areas of expertise.
Ultimately, California voters must weigh the possibility of new treatments against the cost of financing them with debt.
“We want to develop new therapies, and initiatives like what California is doing are well positioned to do that,” Sarpatwari said. “But at the end of the day, they’re only as good as people being able to access them affordably.”
Where did this number come from? And is there any truth to the idea that Trump is responsible for saving 2 million lives from COVID-19? Since Trump continues to use it to claim success, we decided to look into it.
This article was published on Wednesday, October 21, 2020 in Kaiser Health News.
President Donald Trump has repeatedly claimed to have saved 2 million lives from COVID-19 through his actions to combat the disease.
Recently, he made the assertion during the NBC News town hall on Oct. 15 that replaced the second presidential debate.
“But we were expected to lose, if you look at the original charts from original doctors who are respected by everybody, 2,200,000 people,” Trump said. “We saved 2 million people,” he added.
Where did this number come from? And is there any truth to the idea that Trump is responsible for saving 2 million lives from COVID-19? Since Trump continues to use it to claim success, we decided to look into it.
What We Know About the ‘2 Million’
The White House and the Trump presidential campaign did not respond to our request for evidence supporting the idea that roughly 2 million lives were spared.
It appears to have first been mentioned by the president during a March 29 White House coronavirus task force press briefing, when Trump and Dr. Deborah Birx, task force coordinator, explained they were asking Americans to stay home from mid-March through the end of April, because mathematical models showed 1.6 million to 2.2 million people could die from COVID-19.
The warning stemmed from a paper authored by Neil Ferguson, an epidemiology professor at Imperial College London. He modeled how COVID-19 can spread through a population in different scenarios, including what would happen if no interventions were put in place and people continued to live their daily lives as normal.
In the paper, Ferguson wrote, “In total, in an unmitigated epidemic, we would predict approximately 510,000 deaths in [Great Britain] and 2.2 million in the US.”
Ferguson did not respond to our request to talk through the study with him. But in a July email interview with HuffPost, he said Trump’s boasting of saving 2.2 million lives isn’t true, because the pandemic isn’t over.
Andrea Bertozzi, a mathematics professor at UCLA, said it was important to remember the 2.2 million figure was derived from a modeling scenario that would almost certainly never happen — which is that neither the government nor individuals would change their behavior at all in light of COVID-19.
The study didn’t mean to say 2.2 million people were absolutely going to die, but rather to say, “Hold on, if we let this thing run its course, bad things could happen,” said Bertozzi. Indeed, the results from the study did cause government leaders in both the U.S. and the United Kingdom to implement social distancing measures.
Experts also pointed out that the U.S. has the highest COVID-19 death toll of any country in the world — more than 220,000 people — and among the highest death rates, according to the Johns Hopkins Coronavirus Resource Center.
“I don’t think we can say we’ve prevented 2 million deaths, because people are still dying,” said Justin Lessler, an associate professor of epidemiology at Johns Hopkins Bloomberg School of Public Health.
In some instances when using the 2 million estimate, Trump and others in his administration cited the China travel restrictions for saving lives, while other times they’ve credited locking down the economy. We’ll explore whether either statement holds water.
Did Travel Restrictions Do Anything?
Trump implemented travel restrictions for some people traveling from China beginning Feb. 2 and for Europe on March 11. But experts say and reports show the restrictions don’t appear to have had much effect because they were put in place too late and had too many holes.
The Centers for Disease Control and Prevention reported the first cases of coronavirus in the U.S. arrived in mid-January. So, since the travel bans were put in place after COVID-19 was already spreading in the U.S., they weren’t effective, said Josh Michaud, associate director for global health policy at the KFF. (KHN is an editorially independent program of KFF.)
A May study supports that assessment. The researchers found the risk of transmission from domestic air travel exceeded that of international travel in mid-March.
Based on all this, experts said there isn’t evidence to support the idea that the travel restrictions were the principal intervention to reduce the transmission of COVID-19.
What About Lockdowns?
On the other hand, the public health experts we talked to said multipleglobal and U.S.-focused studies show that lockdowns and implementing social distancing measures helped to contain the spread of the coronavirus and thus can be said to have prevented deaths.
However, Trump can’t take full credit for these so-called lockdown measures, which ranged from closing down all but essential businesses to implementing citywide curfews and statewide stay-at-home orders. On March 16, after being presented with the possibility of the national death tally rising to 2.2. million, the White House issued federal recommendations to limit activities that could transmit the COVID-19 virus. But these were just guidelines and were recommended to be in effect only through April 30.
Most credit for putting in place robust social distancing measures belongs to state and local government and public health officials, many of whom enacted stronger policies than those recommended by the White House, our experts said.
“I don’t think you can directly credit the federal government or the Trump administration with the shutdown orders,” said Lessler. “The way our system works is that the power for public health policy lies with the state. And each state was making its own individual decision.”
Some studies also explore the potential human costs of missed opportunities. If lockdowns had been implemented one or two weeks earlier than mid-March, for instance, which is when most of the U.S. started shutting down, researchers estimated that tens of thousands of American lives could have been saved. A model also shows that if almost everyone wore a mask in the U.S., tens of thousands of deaths from COVID-19 could have been prevented.
Despite these scientific findings, Trump started encouraging states — even those with high transmission rates — to open back up in May, after the White House’s recommendations to slow the spread of COVID-19 expired. He has also questioned the efficacy of masks, said he wouldn’t issue a national mask mandate and instead left mask mandate decisions up to states and local jurisdictions.
Our Ruling
President Trump is claiming that without his efforts, there would have been 2 million deaths in the U.S. from COVID-19.
But that 2 million number is taken from a model that shows what would happen without any mitigation measures — that is, if citizens had continued their daily lives as usual, and governments did nothing. Experts said that wouldn’t have happened in real life.
And while lockdowns and social distancing have indeed been proven to prevent COVID-19 illness and deaths, credit for that doesn’t go solely to Trump. The White House issued federal recommendations asking Americans to stay home, but much stronger social distancing measures were enforced by states.
Travel restrictions implemented by Trump perhaps helped hold down transmission in the context of broader efforts, but on their own, they don’t seem to have significantly reduced the transmission rate of the coronavirus.
Much like President Barack Obama, a President Biden could find his health policies initially sidelined by economic issues — in his case, caused by the pandemic.
This article was published on Thursday, October 22, 2020 in Kaiser Health News.
If Joe Biden wins the presidency in November, health is likely to play a high-profile role in his agenda. Just probably not in the way he or anyone else might have predicted.
Barring something truly unforeseen, it's fairly certain that on Jan. 20 the U.S. will still be in the grip of the coronavirus pandemic — and the economic dislocation it has caused. Coincidentally, that would put a new President Biden in much the same place as President Barack Obama at his inauguration in 2009: a Democratic administration replacing a Republican one in the midst of a national crisis.
Obama had only a financial crisis to deal with. Still, Biden would have a couple of advantages his Democratic predecessor lacked, including the fact that, as vice president, he helped guide the country through that financial meltdown. He's also had time to plan how to address the crisis, which was not the case in 2009, when the economy was in freefall just as the new administration was taking office.
But like Obama before him, Biden will face a long must-do list on taking office. He will have to tackle the pandemic and economic crisis before he can turn to some of the big health changes he's promised, such as expanding the reach of the Affordable Care Act, creating a "public option" that would allow every American to enroll in a government-sponsored plan and lowering the eligibility age for Medicare from 65 to 60.
And even if Democrats do retake the Senate majority and keep control of the House, it is unlikely the majority in either chamber will be as large as in 2009, when Obama had 60 Senate votes.
Still, no matter what the partisan makeup of Congress, "priority one is to get the COVID response going," said Len Nichols, a professor of health policy at George Mason University.
Biden's COVID plan includes taking major responsibility for the pandemic back from the states. His federal response would include more money for, and coordination of, testing and contact tracing; ensuring adequate protective equipment for health professionals; and assuring the public that new treatments and vaccines will be based on science, not politics.
In an updated version of his plan, Biden has also promised that one of his first calls if he is elected will be to Dr. Anthony Fauci, the government's top infectious disease expert, who has been deridedby President Donald Trump. "Dr. Fauci will have full access to the Oval Office and an uncensored platform to speak directly to the American people — whether delivering good news or bad," says Biden's website.
Biden's COVID plan also addresses the economy — including calls for emergency paid leave for workers dislocated by the pandemic and more financial aid for workers, families and small businesses.
"If we've learned anything, it is that the health sector and the economy are not two separate spheres. They are connected," said Nichols. "I think health care and the economy are complementary and will be for the foreseeable future."
Assuming Biden gets beyond the pandemic and recession, he could move onto some of his bigger health promises, including expanding eligibility for Medicare, creating a "public option" health plan and boosting premium subsidies for the ACA.
Biden took heat throughout the primaries for his "moderate" approach to improving health insurance access and costs, compared with the "Medicare for All" plans for a government-run system supported by his top rivals, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.). But that doesn't mean his far less sweeping approach would be easy to get through Congress.
"There's a really big difference when you're running the government than when you're running for office," said Dan Mendelson, a former Clinton administration health official and founder of the health consulting firm Avalere Health.
Many of Biden's proposals, including a public option and larger subsidies to help low- and middle-income people pay for insurance, are the very things that an overwhelmingly Democratic Congress could not pass as part of the original Affordable Care Act in 2010. Conservative Democratic senators objected to the plan.
"We pushed," Obama said in a recent interview on the podcast "Pod Save America," talking about the public option. "I needed 60 votes to get it through the Senate. Joe Lieberman, Ben Nelson and a couple others said, 'I'm not voting for a public option.'"
Mendelson said another big obstacle is that for all the detail Biden has in his health plan, concepts like the public option "are not well-defined, and there are many different theories of what it should be and where it should be fielded. There's no common vision about what it really means."
The same thing is true, he added, for something that seems as simple as reducing the Medicare eligibility age. "More than half these people have commercial insurance," he said. "What will happen to them?"
Grace-Marie Turner, of the conservative Galen Institute, suggested Biden — or Trump, if he's reelected — might be better served by pursuing one of the more bipartisan health issues that already have broad support from the public, like prescription drug prices or "surprise" medical bills patients receive after getting care from a doctor outside their insurance network while being treated at an in-network facility. "It would be a big statement," she said. "Whoever wins would then have the wind at their back."
But even those issues have a way of getting complicated. Both Democrats and Republicans say they want to bring down drug prices, but Republicans are vehemently against one of the Democrats' preferred ways of doing that: by allowing Medicare to negotiate with drugmakers. And surprise medical billing has so far defied efforts to fix it, as Congress seems unable to choose between health insurers and health providers, who each want the other to bear the additional costs.
As always, even when health is at the top of the agenda, it proves difficult to address.
Facing a pandemic, record unemployment and unknown future costs for COVID-19 treatments, health insurers selling Affordable Care Act plans to individuals reacted by lowering rates in some areas and, overall, issuing only modest premium increases for 2021.
"What's been fascinating is that carriers in general are not projecting much impact from the pandemic for their 2021 premium rates," said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University in Washington, D.C.
Although final rates have yet to be analyzed in all states, those who study the market say the premium increases they have seen to date will be in the low single digits — and decreases are not uncommon.
That's good news for the more than 10 million Americans who purchase their own ACA health insurance through federal and state marketplaces. The federal market, which serves 36 states, opens for 2021 enrollment Nov. 1, with sign-up season ending Dec. 15. Some of the 14 states and the District of Columbia that operate their own markets have longer enrollment periods.
The flip side of flat or declining premiums is that some consumers who qualify for subsidies to help them purchase coverage may also see a reduction in that aid.
Here are a few things to know about 2021 coverage:
It might cost about the same this year — or even less.
Despite the ongoing debate about the ACA — compounded by a Supreme Court challenge brought by 20 Republican states and supported by the Trump administration — enrollment and premium prices are not forecast to shift much.
"It's the third year in a row with premiums staying pretty stable," said Louise Norris, an insurance broker in Colorado who follows rates nationwide and writes about insurance trends. "We've seen modest rate changes and influx of new insurers."
That relative stability followed ups and downs, with the last big increases coming in 2018, partly in response to the Trump administration cutting some payments to insurers.
Those increases priced out some enrollees, particularly people who don't qualify for subsidies, which are tied both to income and the cost of premiums. ACA enrollment has fallen since its peak in 2016.
Charles Gaba, a web developer who has since late 2013 tracked enrollment data in the ACA on his ACASignups.net website, follows premium changes based on filings with state regulators. Each summer, insurers must file their proposed rates for the following year with states, which have varying oversight powers.
Gaba said the average requested increase next year nationwide is 2.1%. When he looked at 18 states for which regulators have approved insurers' requested rates, the percentage is lower, at 0.4%.
Another study, by KFF, of preliminary premiums filed this summer had similar findings: Premium changes in 2021 would be modest, only a few percentage points up or down. (KHN is an editorially independent program of KFF.Bottom of Form
It's still worth it to shop around.
Actuaries and other experts say premiums vary by state or region — even by insurer — for a number of reasons, including the number and relative market power of insurers or hospitals in an area, which affects the ability of insurers to negotiate rates with providers.
Because subsidies are tied to each region's benchmark plan, and those premium costs may have gone down, subsidies also could decrease. (Benchmark plans are the second-lowest-priced silver plan in a region.)
Switching to the benchmark plan can help consumers maintain how much they spend in premiums.
Enrollees should update their financial information, particularly this year when many are affected by work reduction or job losses. "They might be eligible for a bigger" subsidy, said Myra Simon, executive director of commercial policies for America's Health Insurance Plans, the industry lobbying group.
Enrollees can update their information online, or call their federal or state marketplace for assistance. Insurance brokers, too, can aid people in signing up for ACA plans. When shopping, consumers should check whether the doctors and hospitals they want to use are included in the plan's network.
Premiums are just one part of the equation. Consumers should also look closely at annual deductibles, because the trade-off of going with a lower-cost premium may well be higher annual deductibles that must be met before much of the coverage kicks in.
"We encourage people to consider all their options," said Simon.
What's behind the variation.
Enrollees in some states next year will see premium decreases, according to Gaba's website: Maine, for example, shows a 13% drop in weighted average premium prices, while Maryland's is down almost 12%. At the same time, Indiana's average is up 10%. And Kentucky is up 5%.
Both Maine and Maryland attribute the decrease to state programs that provide reinsurance payments to health insurers to help offset high-cost medical claims.
In Florida, regulators say insurance premiums will rise about 3%, while the state exchange in California is reporting just over a half-percent increase, its lowest average increase since opening in 2014. Officials in California cite factors that include an influx of healthier enrollees and a reduction in fees that insurers pay.
Other factors affecting rates include how much state regulators step in to alter initial rate filings, along with a provision of the ACA that requires insurers to spend at least 80% of revenue on direct medical care. If insurers don't meet that standard, they must issue rebates to policyholders. Many insurers were already on the hook to return money in 2020 for previous years.
Most insurers did not cite additional COVID treatment or testing costs as factors in their requested rate increase, Gaba said. Even those that did, however, mainly found them unnecessary because of reduced expenditures resulting from patients delaying elective care during the spring and summer.
"Some of them thought, 'We're going to make more than we thought this year in profits, so let's not be aggressive with pricing next year,'" said Donna Novak, a member of the American Academy of Actuaries' Individual and Small Group Markets Committee.
A smaller factor may be the repeal of a fee paid by insurers on premiums. Part of the ACA, the fee was permanently eliminatedby the Trump administration effective for 2021.
Your choice of insurers may have widened.
More insurers, including UnitedHealth Group, either stepped back into that individual market or expanded into new counties.
"Insurers are seeing a profit or potential for it," said John Dodd, an insurance broker in Columbus and past president of the Ohio Association of Health Underwriters.
Rates are down in general across his state for ACA plans, he said, and he expects agents to be busier than ever, simply because there are more plan offerings and choices to make and people want help.
Insurers, he said, like the way the ACA is working.
"People on TV who say it's not working, they don't know what they're talking about," said Dodd. "It's working well [for insurers] and every year it gets better."
New stuff in some states, including a public option.
Residents of New Jersey and Pennsylvania will buy coverage from new state-based marketplaces for 2021, after those states pulled out of the federal healthcare.gov, which now covers 36 states.
Lawmakers in those statessaid running their own marketplaces gives them more control and may save them money over time.
In 19 Washington state counties, insurers are offering "public option plans," which have all the standard benefits, including lower deductibles, and must meet additional quality standards.
As envisioned, the public option plans aimed to be less expensive, with the legislation tying payment rates to Medicare. Insurers offering a public option must stick to an aggregate cap of paying doctors, hospitals and other medical providers an average of 160% of what Medicare would pay for the same services.
When the premium rates came in, however, the five insurers offering the plans had varying prices. Not all parts of the state have the option, but where they do, two of the public option insurers have premiums that are either lower than other plans in the area or are the lowest-cost plan the insurer offers.
But three are more expensive.
The state's marketplace staff said the higher prices may reflect a number of things, from difficulty getting the program started during COVID-19 to a lack of incentives to get providers to participate.
It could also just be normal first-year jitters.
"It's Year One. As with any market entry strategy, people are pretty conservative," said Michael Marchand, chief marketing officer of the Washington Health Benefit Exchange.